Article

Novel Approach to Cardiac Alarm Management on Telemetry Units

Authors:
Article

Novel Approach to Cardiac Alarm Management on Telemetry Units

If you want to read the PDF, try requesting it from the authors.

Abstract

General medical-surgical units struggle with how best to use cardiac monitor alarms to alert nursing staff to important abnormal heart rates (HRs) and rhythms while limiting inappropriate and unnecessary alarms that may undermine both patient safety and quality of care. When alarms are more often false than true, the nursing staff's sense of urgency in responding to alarms is diminished. In this syndrome of "clinical alarm fatigue," the simple burden of alarms desensitizes caregivers to alarms. Noise levels associated with frequent alarms may also heighten patient anxiety and disrupt their perception of a healing environment. Alarm fatigue experienced by nurses and patients is a significant problem and innovative solutions are needed. The purpose of this quality improvement study was to determine variables that would safely reduce noncritical telemetry and monitor alarms on a general medical-surgical unit where standard manufacturer defaults contributed to excessive audible alarms. Mining of alarm data and direct observations of staff's response to alarms were used to identify the self-reset warning alarms for bradycardia, tachycardia, and HR limits as the largest contributors of audible alarms. In this quality improvement study, the alarms for bradycardia, tachycardia, and HR limits were changed to "crisis," requiring nursing staff to view and act on the alarm each time it sounded. The limits for HR were HR low 45 bpm and HR high 130 bpm. An overall 89% reduction in total mean weekly audible alarms was achieved on the pilot unit (t = 8.84; P < .0001) without requirement for additional resources or technology. Staff and patient satisfaction also improved. There were no adverse events related to missed cardiac monitoring events, and the incidence of code blues decreased by 50%. Alarms with self-reset capabilities may result in an excess number of audible alarms and clinical alarm fatigue. By eliminating self-resetting alarms, the volume of audible alarms and associated clinical alarm fatigue can be significantly reduced without requiring additional resources or technology or compromising patient safety and lead to improvement in both staff and patient satisfaction.

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

... As Graham and Cvach (2010) studied changes to HR parameters, Whalen et al. (2014) also looked specifically at adjusting heart rate (HR) default limits for the improvement in clinical alarms and prevention of alarm fatigue. For this quality improvement project, HR low limits were changed to a low limit of 45bpm and a high limit of 130bpm. ...
... This demonstrates that even small changes in alarm thresholds can reduce overall clinical alarms. Whalen et al. (2014), also point out that during the implementation of this project allowing for the changes to alarm limits, and the increased education, led to empowering of nurse to modify default alarm settings if an alarm did not indicate the need for clinical intervention (Whalen et al., 2014). ...
... This demonstrates that even small changes in alarm thresholds can reduce overall clinical alarms. Whalen et al. (2014), also point out that during the implementation of this project allowing for the changes to alarm limits, and the increased education, led to empowering of nurse to modify default alarm settings if an alarm did not indicate the need for clinical intervention (Whalen et al., 2014). ...
Preprint
Alarm fatigue is known to be one of the top safety concerns in the healthcare setting. The Joint Commission recognized Alarm safety as one of the 2017 National Patient Safety Goals. Alarm fatigue occurs when a healthcare worker becomes overwhelmed and often desensitized to patient monitor alarms. It has been established that interventions including ECG daily electrode and battery changes, skin prep for electrode placement, and adjusting alarm parameters to fit patient needs can lead to a reduction in false or nuisance alarms. In order for these interventions to be carried out successfully, education of nurses regarding alarm fatigue and interventions for change needs to be completed. Education is one of the most important phases of creating change. The purpose of this program development project was to determine the effectiveness of an educational program on alarm fatigue awareness for telemetry unit nurses. A program development project was developed utilizing a pre-test, educational intervention, and a post-test design. Tests were used to evaluate the nurses’ knowledge improvement related to the educational intervention. Sixteen out of a possible 60 telemetry nurses completed the pretest portion of this quality improvement project. (N=16, 26.6%). Fourteen of a possible 60 nurses attended the educational session and completed the post-test portion of this quality improvement project. (N=14, 23%). For the purpose of presenting the first four questions, only those tests with matching pre-and-post responses were utilized, (N=14). The mean scores from pre-tests were 51.2% and mean post-test scores were 92% which revealed an increase by 40.8% after an educational intervention. The APRN can assist in establishing and implementing an educational program. This educational program can help to implement interventions and provide evidenced based research to support the prevention of alarm fatigue.
... Excess numbers of alarms, a very high false alarm rate, and a disproportionately small number of actionable alarms have desensitized clinical staff to alarms, even when they are critical in nature [5][6][7][8][9]. The physiological monitors are a major contributor to alarm fatigue in critical care areas such as the intensive care unit (ICU), post-anesthesia care unit (PACU), telemetry monitoring units, and emergency departments where patient conditions can deteriorate rapidly [10][11][12]. ...
... Data regarding alarm fatigue originates in descriptive analyses from quality improvement projects aiming to reduce numbers of alarms [5,[7][8][9][10][11][13][14][15]. There is a paucity of information regarding the psycho-behavioral aspects of adjusting physiological monitoring alarm settings. ...
... Trending information regarding heart rate and diagnosis-specific data may improve clinicians' optimization of HR alarm limits, while improving the precision of HR monitoring [11,22]. Some of the current alarms management strategies focus on the "symptom" of high numbers of alarms [9,11,13], but not the cause or contributing factors such as incorrect or inappropriate settings. ...
... Interdisciplinary teams have been identified both in QI projects 47,435,436,[438][439][440] and by experts 441 as essential for addressing alarm management. Typically, teams are composed of nurses, physicians, clinical engineers, quality and safety experts, information technology pro fessionals, and senior hospital leadership. ...
... Typically, teams are composed of nurses, physicians, clinical engineers, quality and safety experts, information technology pro fessionals, and senior hospital leadership. 47,440 Some teams also include a representative from the monitoring equipment manufacturer 438 and families of patients. 436 In an integrative review, an interdisciplinary alarm man CLINICAL STATEMENTS AND GUIDELINES agement committee was identified as key to selecting alarm management strategies. ...
... A monitor alarm assessment includes a collection of alarm signal data to identify the types of alarm conditions that occur within the monitoring system. 47,440 This can be done through an MDDS with annotation, 50 by direct observation, 423 or via video recording. 410,443 The MDDS can produce electronic reports of alarm data in multiple formats such as in tables or graphs. ...
Article
Background and purpose: This scientific statement provides an interprofessional, comprehensive review of evidence and recommendations for indications, duration, and implementation of continuous electro cardiographic monitoring of hospitalized patients. Since the original practice standards were published in 2004, new issues have emerged that need to be addressed: overuse of arrhythmia monitoring among a variety of patient populations, appropriate use of ischemia and QT-interval monitoring among select populations, alarm management, and documentation in electronic health records. Methods: Authors were commissioned by the American Heart Association and included experts from general cardiology, electrophysiology (adult and pediatric), and interventional cardiology, as well as a hospitalist and experts in alarm management. Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process. Authors were assigned topics relevant to their areas of expertise, reviewed the literature with an emphasis on publications since the prior practice standards, and drafted recommendations on indications and duration for electrocardiographic monitoring in accordance with the American Heart Association Level of Evidence grading algorithm that was in place at the time of commissioning. Results: The comprehensive document is grouped into 5 sections: (1) Overview of Arrhythmia, Ischemia, and QTc Monitoring; (2) Recommendations for Indication and Duration of Electrocardiographic Monitoring presented by patient population; (3) Organizational Aspects: Alarm Management, Education of Staff, and Documentation; (4) Implementation of Practice Standards; and (5) Call for Research. Conclusions: Many of the recommendations are based on limited data, so authors conclude with specific questions for further research.
... Successful bundled quality improvement approaches included alteration in default monitor presets (10)(11)(12)(13)(14), daily electrode change (15)(16)(17), alarm customization/alarm "rounds" (10,12,14,(16)(17)(18) , alarm management education (10,19), change in policy (11,20), use of notification delays (12,14,21), histogram-based pulse oximetry (SpO 2 ) alarm tailoring (12,13), and improved displays to aid in nurse-patient assignment (12). The effects of these interventions are summarized in Table 2. Alarms quantities decreased between 18.5% (17) and as much as 89% (11) as did the duration of alarms (a measure of response time) (21) dropped. ...
... Successful bundled quality improvement approaches included alteration in default monitor presets (10)(11)(12)(13)(14), daily electrode change (15)(16)(17), alarm customization/alarm "rounds" (10,12,14,(16)(17)(18) , alarm management education (10,19), change in policy (11,20), use of notification delays (12,14,21), histogram-based pulse oximetry (SpO 2 ) alarm tailoring (12,13), and improved displays to aid in nurse-patient assignment (12). The effects of these interventions are summarized in Table 2. Alarms quantities decreased between 18.5% (17) and as much as 89% (11) as did the duration of alarms (a measure of response time) (21) dropped. ...
... The effects of these interventions are summarized in Table 2. Alarms quantities decreased between 18.5% (17) and as much as 89% (11) as did the duration of alarms (a measure of response time) (21) dropped. One study found that noise levels improved (11). These changes resulted in improved nursing satisfaction/workflow measures (10,16), nursing satisfaction with noise level (10), and improved nurse perception of alarm PPV (10,11). ...
Article
Full-text available
Objective: Alarm fatigue is a widely recognized safety and quality problem where exposure to high rates of clinical alarms results in desensitization leading to dismissal of or slowed response to alarms. Nonactionable alarms are thought to be especially problematic. Despite these concerns, the number of clinical alarm signals has been increasing as an everincreasing number of medical technologies are added to the clinical care environment. Data sources: PubMed, SCOPUS, Embase, and CINAHL. Study selection: We performed a systematic review of the literature focused on clinical alarms. We asked a primary key question; "what interventions have been attempted and resulted in the success of reducing alarm fatigue?" and 3-secondary key questions; "what are the negative effects on patients/families; what are the balancing outcomes (unintended consequences of interventions); and what human factor approaches apply to making an effective alarm?" Data extraction: Articles relevant to the Key Questions were selected through an iterative review process and relevant data was extracted using a standardized tool. Data synthesis: We found 62 articles that had relevant and usable data for at least one key question. We found that no study used/developed a clear definition of "alarm fatigue." For our primary key question 1, the relevant studies focused on three main areas: quality improvement/bundled activities; intervention comparisons; and analysis of algorithm-based false and total alarm suppression. All sought to reduce the number of total alarms and/or false alarms to improve the positive predictive value. Most studies were successful to varying degrees. None measured alarm fatigue directly. Conclusions: There is no agreed upon valid metric(s) for alarm fatigue, and the current methods are mostly indirect. Assuming that reducing the number of alarms and/or improving positive predictive value can reduce alarm fatigue, there are promising avenues to address patient safety and quality problem. Further investment is warranted not only in interventions that may reduce alarm fatigue but also in defining how to best measure it.
... 32 All except 1 study 32 used the monitoring system to record alarm data. Several studies evaluated multicomponent interventions that included combinations of the following: widening alarm parameters, 31,[35][36][37][38] instituting alarm delays, 31,34,36,38 reconfiguring alarm acuity, 35,37 use of secondary notifications, 34 daily change of electrocardiographic electrodes or use of disposable electrocardiographic wires, 32,33,38 universal monitoring in high-risk populations, 31 and timely discontinuation of monitoring in low-risk populations. 38 Four intervention studies met our pre-specified lower risk of bias criteria. ...
... 32 All except 1 study 32 used the monitoring system to record alarm data. Several studies evaluated multicomponent interventions that included combinations of the following: widening alarm parameters, 31,[35][36][37][38] instituting alarm delays, 31,34,36,38 reconfiguring alarm acuity, 35,37 use of secondary notifications, 34 daily change of electrocardiographic electrodes or use of disposable electrocardiographic wires, 32,33,38 universal monitoring in high-risk populations, 31 and timely discontinuation of monitoring in low-risk populations. 38 Four intervention studies met our pre-specified lower risk of bias criteria. ...
... Widening alarm parameter default settings was evaluated in 5 studies: 31,35-38 1 single intervention randomized controlled trial (RCT), 36 and 4 multiple intervention, quasiexperimental studies. 31,35,37,38 In the RCT, using a lower SpO2 limit of 85% instead of the standard 90% resulted in 61% fewer alarms. In the 4 multiple intervention studies, 1 study reported significant reductions in alarm rates (p<0.001), ...
Article
Background: Alarm fatigue from frequent nonactionable physiologic monitor alarms is frequently named as a threat to patient safety. Purpose: To critically examine the available literature relevant to alarm fatigue. Data sources: Articles published in English, Spanish, or French between January 1980 and April 2015 indexed in PubMed, Cumulative Index to Nursing and Allied Health Literature, Scopus, Cochrane Library, Google Scholar, and ClinicalTrials.gov. Study selection: Articles focused on hospital physiologic monitor alarms addressing any of the following: (1) the proportion of alarms that are actionable, (2) the relationship between alarm exposure and nurse response time, and (3) the effectiveness of interventions in reducing alarm frequency. Data extraction: We extracted data on setting, collection methods, proportion of alarms determined to be actionable, nurse response time, and associations between interventions and alarm rates. Data synthesis: Our search produced 24 observational studies focused on alarm characteristics and response time and 8 studies evaluating interventions. Actionable alarm proportion ranged from <1% to 36% across a range of hospital settings. Two studies showed relationships between high alarm exposure and longer nurse response time. Most intervention studies included multiple components implemented simultaneously. Although studies varied widely, and many had high risk of bias, promising but still unproven interventions include widening alarm parameters, instituting alarm delays, and using disposable electrocardiographic wires or frequently changed electrocardiographic electrodes. Conclusions: Physiologic monitor alarms are commonly nonactionable, and evidence supporting the concept of alarm fatigue is emerging. Several interventions have the potential to reduce alarms safely, but more rigorously designed studies with attention to possible unintended consequences are needed.
... Excess numbers of alarms, a very high false alarm rate, and a disproportionately small number of actionable alarms have desensitized clinical staff to alarms, even when they are critical in nature [5][6][7][8][9]. The physiological monitors are a major contributor to alarm fatigue in critical care areas such as the intensive care unit (ICU), post-anesthesia care unit (PACU), telemetry monitoring units, and emergency departments where patient conditions can deteriorate rapidly [10][11][12]. ...
... Data regarding alarm fatigue originates in descriptive analyses from quality improvement projects aiming to reduce numbers of alarms [5,[7][8][9][10][11][13][14][15]. There is a paucity of information regarding the psycho-behavioral aspects of adjusting physiological monitoring alarm settings. ...
... Trending information regarding heart rate and diagnosis-specific data may improve clinicians' optimization of HR alarm limits, while improving the precision of HR monitoring [11,22]. Some of the current alarms management strategies focus on the "symptom" of high numbers of alarms [9,11,13], but not the cause or contributing factors such as incorrect or inappropriate settings. ...
Article
Full-text available
Background Heart rate (HR) alarms are prevalent in ICU, and these parameters are configurable. Not much is known about nursing behavior associated with tailoring HR alarm parameters to individual patients to reduce clinical alarm fatigue. Objectives To understand the relationship between heart rate (HR) alarms and adjustments to reduce unnecessary heart rate alarms. Methods Retrospective, quantitative analysis of an adjudicated database using analytical approaches to understand behaviors surrounding parameter HR alarm adjustments. Patients were sampled from five adult ICUs (77 beds) over one month at a quaternary care university medical center. A total of 337 of 461 ICU patients had HR alarms with 53.7% male, mean age 60.3 years, and 39% non-Caucasian. Default HR alarm parameters were 50 and 130 beats per minute (bpm). The occurrence of each alarm, vital signs, and physiologic waveforms was stored in a relational database (SQL server). Results There were 23,624 HR alarms for analysis, with 65.4% exceeding the upper heart rate limit. Only 51% of patients with HR alarms had parameters adjusted, with a median upper limit change of +5 bpm and -1 bpm lower limit. The median time to first HR parameter adjustment was 17.9 hours, without reduction in alarms occurrence (p = 0.57). Conclusions HR alarms are prevalent in ICU, and half of HR alarm settings remain at default. There is a long delay between HR alarms and parameters changes, with insufficient changes to decrease HR alarms. Increasing frequency of HR alarms shortens the time to first adjustment. Best practice guidelines for HR alarm limits are needed to reduce alarm fatigue and improve monitoring precision.
... A phenomenon called "alarm fatigue" develops from continued exposure to the drone of beeping environmental noises, with the clinician becoming desensitized and ignoring or mismanaging alarms. [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18] In 2013, The Joint Commission made clinical alarm management a national patient safety goal to help address the alarm fatigue phenomenon. Between January 2009 and June 2012, 98 alarm-related events were reported to The Joint Commission. ...
... 26 Furthermore, efforts to reduce alarms and the number of patients being monitored have not reported increases in patient morbidity or mortality. [18][19][20]24,27,28 These studies suggest a more discriminatory look at the appropriate need and practices for telemetry monitoring in patients is needed. ...
... According to the literature, customizing alarm parameters for patients can decrease unnecessary alarms. 15,18,19,28 In the health care setting, clinical alarms are necessary to safely care for a multitude of patients. In a critical care setting, a caregiver can be subject to 140 to 400 alarms per patient day. ...
Article
Introduction: The research literature is replete with evidence that alarm fatigue is a real phenomenon in the clinical practice environment and can lead to desensitization of the need to respond among nursing staff. A few studies attest to the effectiveness of incorporating parts of the American Association of Critical-Care Nurses recommended nursing practices for alarm management. No studies could be found measuring the effectiveness of the American Association of Critical-Care Nurses recommendations in their entirety or the effectiveness of a nursing-driven, evidence-based, patient-customized monitoring bundle. Purpose/research question: The purpose of this study was to describe the effect of implementing CEASE, a nurse-driven, evidence-based, patient-customized monitoring bundle on alarm fatigue. CEASE is an acronym for Communication, Electrodes (daily changes), Appropriateness (evaluation), Setup alarm parameters (patient customization), and Education (ongoing). Research questions: (1) In a 36-bed intensive care unit/step-down unit (ICU/SDU) with continuous hemodynamic and respiratory monitoring, does application of an evidence-based, patient-customized monitoring bundle compared with existing monitoring practice lead to less alarm fatigue as measured by the number of hemodynamic and respiratory monitoring alarms? (2) In a 36-bed ICU/SDU with continuous hemodynamic and respiratory monitoring, does application of an evidence-based, patient-customized monitoring bundle compared with existing monitoring practice lead to less alarm fatigue as measured by duration of alarms? and (3) In a 36-bed ICU/SDU with continuous hemodynamic and respiratory monitoring, does application of an evidence-based, patient-customized monitoring bundle compared with existing monitoring practice lead to less alarm fatigue as measured by nurse perception? Methods: This was an institutional review board approved exploratory, nonrandomized, pretest and posttest, 1-group, quasi-experimental study, without-comparators design describing difference in pretest and posttest measures following CEASE Bundle implementation. The study was conducted over a 6-month period. Convenience sample of 74 registered nurses staffing a 36-bed ICU/SDU using the CEASE Bundle participated. Preimplementation/postimplementation number of alarms and alarm duration time for a 30-day period were downloaded from the monitoring system and compared. Nurses completed an electronic 36-item Clinical Alarms Survey provided by the Healthcare Technology Foundation: 35 before implementation and 18 after implementation. Researchers measured CEASE alarm bundle adherence. χ and t-tests determined statistical significance. Results: Total number of monitoring alarms decreased 31% from 52 880 to 36 780 after CEASE Bundle implementation. Low-priority Level 1 alarms duration time significantly decreased 23 seconds (t = 1.994, P = .045). Level 2 duration time did not change. High-priority Level 3 alarms duration time significantly increased to 246 seconds (t = 4.432, P < .0001). CEASE alarm bundle adherence significantly improved to 22.4% (χ = 5.068, P = .0244). Nurses perceived a significant decrease in nuisance alarm occurrence (68% to 44%) postimplementation (χ = 3.243, P = .0417). No adverse patient events occurred. Conclusions: Decreased total number of monitoring alarms improved nurse perception of alarm fatigue. Continued monitoring of CEASE Bundle adherence by nursing staff is required. Longer high-priority Level 3 alarms duration suggests need for further research.
... 15 Previous interventions modifying default alarm settings have done so by widening alarm parameters, increasing alarm delays, or adjusting alarm acuity. [16][17][18][19][20] Widening default alarm parameters, including disabling some alarms completely, is more widely applicable to the many different types of alarms that are recorded, compared with other alarm modification interventions, and has reduced the amount of alarms generated across various settings. [17][18][19] Expanding alarm parameters decreases the alarm load by increasing the acceptable threshold for physiologic deviation from the norm in a nonalarm state. ...
... [16][17][18][19][20] Widening default alarm parameters, including disabling some alarms completely, is more widely applicable to the many different types of alarms that are recorded, compared with other alarm modification interventions, and has reduced the amount of alarms generated across various settings. [17][18][19] Expanding alarm parameters decreases the alarm load by increasing the acceptable threshold for physiologic deviation from the norm in a nonalarm state. Certain nonactionable alarms do not monitor a range or threshold but rather detect a binary state (ie, whether a condition is filled or not), and modifying these alarms necessitates switching them off completely. ...
... For example, previous studies in the cardiac care setting have focused on reducing false alarms generated from electrocardiogram leads and wires while another focused on reducing heart rate-related alarms, implying that these alarms were both frequent and often insignificant. 19,25,26 In the intensive care setting, relative proportions of alarm categories can fluctuate, as evidenced by the proportional increase (44%-62%) in parameter alarms between the baseline and preintervention data. These fluctuations can arise from individual patient outliers who generate a disproportionately large number of alarms or from patients who are triggering the alarms for clinically relevant reasons. ...
Article
Background: Nonactionable alarms comprise over 70% of alarms and contribute a threat to patient safety. Few studies have reported approaches to translate and sustain these interventions in clinical settings. Purpose: This study tested whether an interprofessional team-based approach can translate and implement effective alarm reduction interventions in the adult intensive care unit. Methods: The study was a prospective, cohort, pre- and postdesign with repeated measures at baseline (preintervention) and post-phase I and II intervention periods. The settings for the most prevalent nonactionable arrhythmia and bedside parameter alarms were adjusted during phases I and II, respectively. Results: The number of total alarms was reduced by 40% over a 14-day period after both intervention phases were implemented. The most prevalent nonactionable parameter alarms deceased by 47% and arrhythmia alarms decreased by 46%. Conclusions: It is feasible to translate and sustain system-level alarm management interventions addressing alarm fatigue using an interprofessional team-based approach.
... 21 With the ubiquitous use of cardiac monitoring clinical alarm fatigue has been found to be a major technology hazard. 22 Thus, a smarter alarm is a necessity in the future of the ICU. In one study, current electrocardiogram (ECG) monitors were reconfigured to suppress some spurious warnings, which reduced the amount of spurious or nuisance alarms, in turn improving patient satisfaction and reducing alarm fatigue. ...
... In one study, current electrocardiogram (ECG) monitors were reconfigured to suppress some spurious warnings, which reduced the amount of spurious or nuisance alarms, in turn improving patient satisfaction and reducing alarm fatigue. 22 Dynamically annotated visualizations have been proposed as a replacement for traditional displays, which tend to have more intrusive alerts, which often get turned off or ignored. 23 Current device-specific monitoring is only able to alert health care providers on the basis of a set of predefined conditions. ...
Background: The transition away from written documentation and analog methods has opened up the possibility of leveraging data science and analytic techniques to improve health care. In the implementation of data science techniques and methodologies, high-acuity patients in the ICU can particularly benefit. The Principles of Automation for Patient Safety in Intensive Care (PASPIC) framework draws on Billings's principles of human-centered aviation (HCA) automation and helps in identifying the advantages, pitfalls, and unintended consequences of automation in health care. The framework and its key characteristics: Billings's HCA principles are based on the premise that human operators must remain "in command," so that they are continuously informed and actively involved in all aspects of system operations. In addition, automated systems need to be predictable, simple to train, to learn, and to operate, and must be able to monitor the human operators, and every intelligent system element must know the intent of other intelligent system elements. In applying Billings's HCA principles to the ICU setting, PAPSIC has three key characteristics: (1) integration and better interoperability, (2) multidimensional analysis, and (3) enhanced situation awareness. Recommendations: PAPSIC suggests that health care professionals reduce overreliance on automation and implement "cooperative automation" and that vendors reduce mode errors and embrace interoperability. Conclusion: Much can be learned from the aviation industry in automating the ICU. Because it combines "smart" technology with the necessary controls to withstand unintended consequences, PAPSIC could help ensure more informed decision making in the ICU and better patient care.
... 49 53 55 56 Importantly, incorporating delays prior to firing alarms, 17 47 suspending alarms temporarily prior to patient or staff manipulation, 17 eliminating the self-resetting function in alarms 53 or standardising alarm defaults across relevant units, departments or areas were suggested as an effective improvement effort. 53 Interviewees perceived that the process of resetting or modifying alarm settings as too variable, non-standardised and cumbersome. This perception led to staff confusion and frustration. ...
... 10 17 53 57 The included studies focused on training and education on configuring alarms, for example, individualising and modifying alarm parameter defaults, 10 48 52 or eliminating false alarms and appropriately adjusting alarms in real time. 53 Some studies integrated interactive educational activities as part of alarm intervention such as during daily stand-ups 48 or clinical rounds. 54 Several studies suggested the importance to conduct alarm training programmes prior to implementing new devices and continuously in addressing staff needs in dealing with alarming medical devices in the clinical environment where the devices were used. ...
Article
Full-text available
Objective To provide an overview of documented studies and initiatives that demonstrate efforts to manage and improve alarm systems for quality in healthcare by human, organisational and technical factors. Methods A literature review, a grey literature review, interviews and a review of alarm-related standards (IEC 60601-1-8, IEC 62366-1:2015 and ANSI/Advancement of Medical Instrumentation HE 75:2009/2013) were conducted. Qualitative analysis was conducted to identify common themes of improvement elements in the literature and grey literature reviews, interviews and the review of alarm-related standards. Results 21 articles and 7 publications on alarm quality improvement work were included in the literature and grey literature reviews, in which 10 themes of improvement elements were identified. The 10 themes were categorised into human factors (alarm training and education, multidisciplinary teamwork, alarm safety culture), organisational factors (alarm protocols and standard procedures, alarm assessment and evaluation, alarm inventory and prioritisation, and sharing and learning) and technical factors (machine learning, alarm configuration and alarm design). 26 clinicians were interviewed. 9 of the 10 themes were identified from the interview responses. The review of the standards identified 3 of the 10 themes. The study findings are also presented in a step-by-step guide to optimise implementation of the improvement elements for healthcare organisations. Conclusions Improving alarm safety can be achieved by incorporating human, organisational and technical factors in an integrated approach. There is still a gap between alarm-related standards and how the standards are translated into practice, especially in a clinical environment that uses multiple alarming medical devices from different manufacturers. Standardisation across devices and manufacturers and the use of machine learning in improving alarm safety should be discussed in future collaboration between alarm manufacturers, end users and regulators.
... Clinicians' failure to respond to alarms has been directly linked to patient deaths, serious injury, and prolonged hospitalization (Jones, 2014;Xiao et al., 2004). Concern about alarm fatigue and patient safety has driven a large volume of research focused on increasing alarm reliability and reducing alarm frequency associated with patient monitoring (Dewan et al., 2019;Drew et al., 2014;McGrath et al., 2016;Whalen et al., 2014). ...
... However, the findings should not be taken to suggest that alarm fatigue does not occur, or that initiatives to reduce the volume of alarms in hospital units should be abandoned. Indeed, there are many reports of such initiatives reducing annoyance and improving responsiveness without apparent harm to patients (Graham and Cvach, 2010;Ruppel, De Vaux et al., 2018;Whalen et al., 2014). In addition, much alarm fatigue research has been done in ICUs, which produce a great many physiological parameter alarms (Bonafide et al., 2015;Chambrin et al., 1999;Deb and Claudio, 2015;Dewan et al., 2019;Drew et al., 2014;Lawless, 1994;Siebig et al., 2010), whereas our study did not include the ICU. ...
Article
A fieldwork study conducted in six units of a major metropolitan Australian hospital revealed that nurses’ attitudes towards alarms are influenced by each unit’s physical layout and caseload. Additionally, nurses relied heavily on both non-actionable and actionable alarms to maintain their awareness of the status of their patients’ wellbeing, and used auditory alarms beyond the scope of their intended design. Results suggest that before reducing or removing auditory alarms from the clinical environment to improve patient safety, it is important to understand how nurses in different clinical contexts use current alarm systems to extract meaningful information. Such an understanding could guide appropriate alarm reduction strategies and guide alternative design solutions to support nurses’ situation awareness during monitoring.
... Published interventions implemented in clinical settings have been primarily quality improvement projects, often bundling several components together. [9][10][11][12][13] Although these projects have resulted in a reduction of 43% to 89% of total alarms on the clinical units where they were implemented, [9][10][11][12][13] it was generally not possible to determine which component of the intervention was most effective. Moreover, the projects often lacked statistical evaluation and were not generalizable beyond the setting. ...
... Published interventions implemented in clinical settings have been primarily quality improvement projects, often bundling several components together. [9][10][11][12][13] Although these projects have resulted in a reduction of 43% to 89% of total alarms on the clinical units where they were implemented, [9][10][11][12][13] it was generally not possible to determine which component of the intervention was most effective. Moreover, the projects often lacked statistical evaluation and were not generalizable beyond the setting. ...
Article
Background: Alarm fatigue threatens patient safety by delaying or reducing clinician response to alarms, which can lead to missed critical events. Interventions to reduce alarms without jeopardizing patient safety target either inaccurate or clinically irrelevant alarms, so assessment of alarm accuracy and clinical relevance may enhance the rigor of alarm intervention studies done in clinical units. Objectives: To (1) examine approaches used to measure accuracy and/or clinical relevance of physiological monitor alarms in intensive care units and (2) compare the proportions of inaccurate and clinically irrelevant alarms. Methods: An integrative review was used to systematically search the literature and synthesize resulting articles. Results: Twelve studies explicitly measuring alarm accuracy and/or clinical relevance on a clinical unit were identified. In the most rigorous studies, alarms were annotated retrospectively by obtaining alarm data and parameter waveforms rather than being annotated in real time. More than half of arrhythmia alarms in recent studies were inaccurate. However, contextual data were needed to determine alarms' clinical relevance. Proportions of clinically irrelevant alarms were high, but definitions of clinically irrelevant alarms often included inaccurate alarms. Conclusions: Future studies testing interventions on clinical units should include alarm accuracy and/or clinical relevance as outcome measures. Arrhythmia alarm accuracy should improve with advances in technology. Clinical interventions should focus on reducing clinically irrelevant alarms, with careful consideration of how clinical relevance is defined and measured.
... The many problems associated with clinical alarms are well docu- mented in the literature. Key among the problems is the issue of 'alarm fatigue' -an often-noted, but not clearly understood, description of a problem which stems from a combination of high false alarm rates, meaningless or difficult-to-understand alarms, noise, excessive mon- itoring, and other issues surrounding good practice (Cvach, 2012;Deb and Claudio, 2015;Drew et al., 2014;Kristensen et al., 2017;Sendelbach and Funk, 2013;Welch, 2011;Whalen et al., 2014). Not least of the problems associated with audible alarm signals specifically is that their design is very far from ideal, with alarm signals typically found to be difficult to learn and remember (Atyeo and Sanderson, 2015;Edworthy et al., 2014;Lacherez et al., 2007;Sanderson et al., 2006;Wee and Sanderson, 2008). ...
Article
Very little is known about people's ability to localize sound under varying workload conditions, though it would be expected that increasing workload should degrade performance. A set of eight auditory clinical alarms already known to have relatively high localizability (the ease with which their location is identified) when tested alone were tested in six conditions where workload was varied. Participants were required to indicate the location of a series of alarms emanating at random from one of eight speaker locations. Additionally, they were asked to read, carry out mental arithmetic tasks, be exposed to typical ICU noise, or carry out either the reading task or the mental arithmetic task in ICU noise. Performance in the localizability task was best in the control condition (no secondary task) and worst in those tasks which involved both a secondary task and noise. The data does therefore demonstrate the typical pattern of increasing workload affecting a primary task in an area where there is little data. In addition, the data demonstrates that performance in the control condition results in a missed alarm on one in ten occurrences, whereas performance in the heaviest workload conditions results in a missed alarm on every fourth occurrence. This finding has implications for the understanding of both 'inattentional deafness' and 'alarm fatigue' in clinical environments.
... [35,[58][59][60][61]. Table 1 summarizes eight different approaches being explored to solve the continuing alarm safety crisis. Research has shown the potential to reduce some frequency of false or nonactionable alarms/alerts through (see Table 1A and 1B): re-configuration of the alarm parameter limits [60,[62][63][64]; alarm escalation [65], individualizing alarm configuration for each patient [66]; improved leads connection [67,68]; and policies for integrated 'middleware' data environments [69,70]; Other studies show advancement of integrated multi-parameter algorithms [71][72][73][74][75]. This focus over the last three decades on reducing alarm frequency [76,77], however, has been criticized as being largely ineffective [78], with only a couple exceptions [48,79]. ...
Article
Full-text available
Objective This study evaluates the potential for improving patient safety by introducing a metacognitive attention aid that enables clinicians to more easily access and use existing alarm/alert information. It is hypothesized that this introduction will enable clinicians to easily triage alarm/alert events and quickly recognize emergent opportunities to adapt care delivery. The resulting faster response to clinically important alarms/alerts has the potential to prevent adverse events and reduce healthcare costs. Materials and methods A randomized within-subjects single-factor clinical experiment was conducted in a high-fidelity 20-bed simulated acute care hospital unit. Sixteen registered nurses, four at a time, cared for five simulated patients each. A two-part highly realistic clinical scenario was used that included representative: tasking; information; and alarms/alerts. The treatment condition introduced an integrated wearable attention aid that leveraged metacognition methods from proven military systems. The primary metric was time for nurses to respond to important alarms/alerts. Results Use of the wearable attention aid resulted in a median relative within-subject improvement for individual nurses of 118% (W = 183, p = 0.006). The top quarter of relative improvement was 3,303% faster (mean; 17.76 minutes reduced to 1.33). For all unit sessions, there was an overall 148% median faster response time to important alarms (8.12 minutes reduced to 3.27; U = 2.401, p = 0.016), with 153% median improvement in consistency across nurses (F = 11.670, p = 0.001). Discussion and conclusion Existing device-centric alarm/alert notification solutions can require too much time and effort for nurses to access and understand. As a result, nurses may ignore alarms/alerts as they focus on other important work. There has been extensive research on reducing alarm frequency in healthcare. However, alarm safety remains a top problem. Empirical observations reported here highlight the potential of improving patient safety by supporting the meta-work of checking alarms.
... A quality improvement project completed at Boston Medical Center, published in 2014, aimed to reduce non critical alarms as they relate to default parameters set by the alarm system manufacturer. Also, the study explored nurse perceptions of noise level and their satisfaction (Whalen et al., 2014). In regard to satisfaction with the interventions set in place, which included, for example, a broadening the default range of normal values, the nurses had an improvement in their level of satisfaction in addition to a reported a 64% improvement in acceptable noise level from pre to postintervention. ...
Article
A phenomenon called alarm fatigue has been identified as an outcome of nearly 40 different alarms that sound at any given time in the Intensive Care Unit (ICU) (Borowski et al., 2011). Alarm fatigue can result in impaired recognition of worsening patient conditions and has been implicated in fatal patient events (Kowalczyk, 2010; Altimari, 2017). A quality improvement research study (QIRS) was conducted, aimed at reducing total alarms including noncritical (clinically irrelevant) and false alarms that contribute to the incidence of alarm fatigue and the potential for unsafe conditions. The project included exploration of the critical care nurse’s attitudes toward alarms, review of the existing evidence based practice policy on clinical alarm management and introduction of a new bedside alarm parameter verification called an “Alarm Check”. Measurements included: alarm rates collected pre and postinitiation of the educational sessions, as well as administration of the Healthcare Technology Foundation’s Alarm Survey. There was a statistically significant decrease in alarm frequency rates after the intervention. Secondly there were statistically significant decrease in noncritical alarm frequencies, but not false alarm rates. There was, however a decrease in the number of false alarms suggesting a clinical significance. These evidence based interventions suggest simple yet effective ways at reducing alarm frequencies and therefore the incidence of potential alarm fatigue.
... [13] Interventions to mitigate non-actionable alarms, including better ECG electrode placement, adjusting alarm thresholds, and education on monitor capabilities and alarms, have resulted in a 12% to 89% reduction in these types of alarms. [4,6,7,[14][15][16][17][18] The recommendations to reduce the non-actionable alarms of physiologic, ECG, and pulse oximetry monitors are not applicable to infusion pumps. Most infusion pump alarms are actionable, that is, they continually alarm until addressed by clinical staff. ...
Article
Full-text available
Background: The variety of alarms from all types of medical devices has increased from 6 to 40 in the last three decades, with today's most critically ill patients experiencing as many as 45 alarms per hour. Alarm fatigue has been identified as a critical safety issue for clinical staff that can lead to potentially dangerous delays or nonresponse to actionable alarms, resulting in serious patient injury and death. To date, most research on medical device alarms has focused on the nonactionable alarms of physiological monitoring devices. While there have been some reports in the literature related to drug library alerts during the infusion pump programing sequence, research related to the types and frequencies of actionable infusion pump alarms remains largely unexplored. Objective: The objectives of this study protocol are to establish baseline data related to the types and frequency of infusion pump alarms from the B. Braun Outlook 400ES Safety Infusion System with the accompanying DoseTrac Infusion Management Software. Methods: The most recent consecutive 60-day period of backup hospital data received between April 2014 and February 2017 from 32 United States-based hospitals will be selected for analysis. Microsoft SQL Server (2012 - 11.0.5343.0 X64) will be used to manage the data with unique code written to sort data and perform descriptive analyses. A validated data management methodology will be utilized to clean and analyze the data. Data management procedures will include blinding, cleaning, and review of existing infusion data within the DoseTrac Infusion Management Software databases at each hospital. Patient-identifying data will be removed prior to merging into a dedicated and secure data repository. This pooled data will then be analyzed. Results: This exploratory study will analyze the aggregate alarm data for each hospital by care area, drug infused, time of day, and day of week, including: overall infusion pump alarm frequency (number of alarms per active infusion), duration of alarms (average, range, median), and type and frequency of alarms distributed by care area. Conclusions: Infusion pump alarm data collected and analyzed in this study will be used to help establish a baseline of infusion pump alarm types and relative frequencies. Understanding the incidences and characteristics of infusion pump alarms will result in more informed quality improvement recommendations to decrease and/or modify infusion pump alarms, and potentially reduce clinical staff alarm fatigue and improve patient safety. . Registered report identifier: RR1-10.2196/10446.
... Until a national summit in the United States in 2011, little was being done about the general problem of alarm condition overuse. Now, however, there are well-documented and successful attempts to reduce the problem of overalarming in general (Cvach, 2012;Welch 2011;Whalen et al., 2014). ...
Article
The reserved set of audible alarm signals embodied within the global medical device safety standard, IEC 60601-1-8, is known to be problematic and in need of updating. The current alarm signals are not only suboptimal, but there is also little evidence beyond learnability (which is known to be poor) that demonstrates their performance in realistic and representative clinical environments. In this article, we describe the process of first designing and then testing potential replacement audible alarm signals for IEC 60601-1-8, starting with the design of several sets of candidate sounds and initial tests on learnability and localizability, followed by testing in simulated clinical environments. We demonstrate that in all tests, the alarm signals selected for further development significantly outperform the current alarm signals. We describe the process of collecting considerably more data on the performance of the new sounds than exists for the current sounds, which ultimately will be of use to end users. We also reflect on the process and practice of working with the relevant committees and other practical issues beyond the science, which also need constant attention if the alarms we have developed are to be included successfully in an updated version of the standard.
... Although physiologic monitor alarms have received great attention during the previous five years, little work has been reported regarding ventilator alarms. [1][2][3][4][5][6][7][8] Among the ECRI Institute's top 10 health technology hazards for 2017, ventilator alarm management was listed as the third greatest hazard because of the unique challenges that ventilators pose to the healthcare team. 9 Although the physiologic monitors on a care unit typically are from a single manufacturer, multiple brands of ventilators often are found in an intensive care unit (ICU). ...
Article
Full-text available
As an entrepreneur, unexpected challenges are going to constitute the majority of your workdays. It might be something large, like a protracted-committed worker who determined to give up or a new competitor emerging to your vicinity, or something small, like a deadline that’s getting driven back due to technical troubles. Learning to stand and conquer those demanding situations without dropping your cool or compromising your long-term desires is one of the maximum crucial -- yet most difficult elements of becoming an entrepreneur. Personalities who opt for to devise tend to have a tougher time coping with unforeseen challenges than personalities who thrive in an improvisational putting, but surprising challenges are universally demanding. By way of nature, they’re unpredictable and regularly stand up in sudden, unanticipated methods. They may disrupt previously existing plans or boom the amount of time, money or effort vital to finish an in any other case honest venture.
... Consider a protocol to allow nurses to adjust alarm settings. 10 -For example: Protocol may allow staff to adjust monitor alarms by 10% above or below the unit's preset alarm limits without a physician order, or protocol may allow two nurses to review and approve a change in the patient's alarm settings without a physician order. 3. When a patient has frequent, nonactionable alarms, consider adjusting nonactionable alarms to a lower priority level (such as informational or, if permitted by hospital policy, to "off"). ...
... These findings are particularly relevant to physiological-based alarming thresholds (e.g., pulse oximetry), in which some hospitals have altered criteria to be more conservative (i.e., MP) to combat excessive false alarms (Whalen et al., 2014). Similarly, the error bias of in-vehicle collision-avoidance systems depends upon driving style, where drivers with shorter headways experience more misses and drivers with longer headways experience more false alarms (Lees, 2010, p. 38;Ben-Yaacov, Maltz, & Shinar, 2002;Maltz & Shinar, 2004). ...
Article
Full-text available
Objective: This study provides a theoretical link between trust and the compliance–reliance paradigm. We propose that for trust mediation to occur, the operator must be presented with a salient choice, and there must be an element of risk for dependence. Background: Research suggests that false alarms and misses affect dependence via two independent processes, hypothesized as trust in signals and trust in nonsignals. These two trust types manifest in categorically different behaviors: compliance and reliance. Method: Eighty-eight participants completed a primary flight task and a secondary signaling system task. Participants evaluated their trust according to the informational bases of trust: performance, process, and purpose. Participants were in a high- or low-risk group. Signaling systems varied by reliability (90%, 60%) within subjects and error bias (false alarm prone, miss prone) between subjects. Results: False-alarm rate affected compliance but not reliance. Miss rate affected reliance but not compliance. Mediation analyses indicated that trust mediated the relationship between false-alarm rate and compliance. Bayesian mediation analyses favored evidence indicating trust did not mediate miss rate and reliance. Conditional indirect effects indicated that factors of trust mediated the relationship between false-alarm rate and compliance (i.e., purpose) and reliance (i.e., process) but only in the high-risk group. Conclusion: The compliance–reliance paradigm is not the reflection of two types of trust. Application: This research could be used to update training and design recommendations that are based upon the assumption that trust causes operator responses regardless of error bias.
... Although strong observational alarm research exists [7,14,19], few rigorous intervention studies to address alarm fatigue have been undertaken in clinical settings [3]. Other investigators, primarily implementing quality improvement bundles, have attempted to demonstrate reduction in alarms using a pre/post design [8,9,13,20,21]. Although they found reductions in alarm rates after the intervention, comparing the magnitude of our results to other studies is challenging because of variation in the way alarm rates were measured and how alarm reduction was calculated. ...
Article
Full-text available
Background: Clinicians in intensive care units experience alarm fatigue related to frequent false and non-actionable alarms produced by physiologic monitors. To reduce non-actionable alarms, alarm settings may need to be customized for individual patients; however, nurses may not customize alarms because of competing demands and alarm fatigue. Objective: To examine the effectiveness and acceptance of physiologic monitor software to support customization of alarms. Methods: This pre/post intervention study was conducted in a 56-bed medical intensive care unit. IntelliVue® Alarm Advisor customization support software for alarm limit violations was installed on all monitors and education on its use provided. For 2 months before and after implementation of the software, data were collected on patient characteristics from the electronic health record, alarm counts and duration from the monitoring system, and nurses' experience of alarms from a survey. Results: Medium-priority heart rate, respiratory rate, and arterial pressure alarms were significantly reduced after software implementation (9.3%, 11.8%, and 15.9% reduction respectively; p<0.001 for all). The duration of these alarms was also significantly shorter (7.8%, 13.3%, and 9.3% reduction respectively; p<0.05 for all). The number and duration of SpO2 alarms did not decrease (p>0.05 for both). Patients post-intervention had worse Glasgow Coma Scale scores (p = 0.014), but otherwise were comparable to those pre-intervention. Nurses reported less time spent on non-actionable alarms post-intervention than pre-intervention (p = 0.026). Also lower post-intervention were the proportions of nurses who reported that alarms disturbed their workflow (p = 0.027) and who encountered a situation where an important alarm was ignored (p = 0.043). The majority (>50%) agreed that the software supported setting appropriate alarm limits and was easy to use. Conclusion: Alarm customization software was associated with a reduction in alarms. Use of software to support nurses' recognition of trends in patients' alarms and facilitate changes to alarm settings may add value to alarm reduction initiatives.
... [1,17] Moreover, unnecessary use of telemetry has resulted in escalating costs of care [10,18] and declining clinical employee job satisfaction. [19] The current study represents an attempt at tackling this highly complex set of interrelated problems. As with many domains within health care, potential solutions involve the implementation of more accurate hardware and software systems, better provider education regarding telemetry use, appropriately implemented clinical integration, as well as greater involvement of patient/family as stakeholders in acuity escalation scenarios. ...
Article
Full-text available
Introduction: Unrecognized clinical patient deterioration (CPD) is a precursor to preventable morbidity and mortality among hospitalized patients. The current standard of intermittent vital signs and physical assessments is inadequate for detecting early CPD and thus prevention of cardiopulmonary events. Continuous oximetry monitoring using a SafetyNet monitoring system (SNMS) may help facilitate early recognition of CPD and early intervention. However, some of the concerns regarding continuous monitoring systems include cost and alarm fatigue. We hypothesized that deployment of SNMS at our institution would result in improved detection of patient deterioration, fewer Intensive Care Unit (ICU) transfers, and reduced telemetry usage. Methods: We conducted a post hoc analysis of data from a quasi-experimental quality improvement project that took place on medical-surgical units (MSUs) at a large, tertiary referral center between January 1, 2015, and December 31, 2016. The 24-month study period included a 12-month pre-SNMS period (January-December 2015) and a 12-month post-SNMS period (January-December 2016). Clinical data were collected on two adjacent MSUs ("P8" and "P9") with "P8" serving as the control unit where SNMS was not deployed. The primary study outcome was rate of ICU transfers tracked as transfers per 1000 patient-days. Telemetry usage and nonclinical alarm burden were our secondary outcomes. Estimated cost-saving analysis was also performed based on the reduction of ICU transfers. Results: The 24-month study period encompassed 21,189 patient-days on the P9 MSU (11,702 pre-SNMS and 9487 post-SNMS) and 23,388 patient-days on the P8 MSU (13,616 pre-SNMS and 9772 post-SNMS). The median case-mix index (a measure of patient acuity based on comorbidities) was higher for P9 than P8 during the duration of the study (2.08 [interquartile range (IQR) 1.98-2.17] vs. 1.67 [IQR 1.64-1.76], respectively). The rate of ICU transfers per 1000 patient-days on the P9 MSU declined from 11.7 during preintervention period to 8.8 post-SNMS implementation (P < 0.03), whereas the comparison unit demonstrated no change. Mean telemetry usage post‐SNMS implementation significantly decreased on the P9 unit (21.6 to 16.5 per 1000 patient‐days, P < 0.01). Based on the observed difference of 38 ICU transfers between pre‐ and post‐SNMS periods, the estimated cost savings for our Network were $902,386. Conclusions: The current standard of inpatient monitoring through intermittent vital sign sampling, physical examination assessments, and continuous telemetry for patients deemed to be “high‐risk” is ineffective in detecting early CPD. This study suggests that implementation of SNMS may help reduce ICU transfers (and associated costs) while at the same time decreasing the reliance on telemetry monitoring. The following core competencies are addressed in this article: Interpersonal and communication skills, Practice‐based learning and improvement, Systems-based practice.
... Several reviews have been conducted on the problem of alarm fatigue [58,66]. Some approaches to addressing the problem include connecting alarms with escalation protocols to pagers [67], adjusting alarm thresholds and delays [68,69], tailoring thresholds to the individual patient [59,70], and scaling alerts to severity [71]. ...
Chapter
Failure to rescue (FTR) is death due to a complication in hospitalized patients. Although complications have varied causation, the common end manifestation prior to death is the development of physiologic instability manifested by abnormalities in vital signs evolving to compromise of end-organ perfusion and metabolic derangement due to tissue hypoperfusion. In order to prevent FTR, instability must first be detected by clinicians and then recognized as important before supportive or rescue action can be initiated. This chapter explores factors which contribute to FTR. They include patient-level factors (static and dynamic patient data and surveillance) and hospital- and system-level factors (staff education, staff-level and temporal variation, lack of consistent clinician exposure to instability, lack of situation and human factors awareness, barriers to care escalation). Understanding the complexity of the interrelationships impacting FTR may assist in developing and implementing interventions to improve clinician’s ability to utilize medical emergency team resources and decrease FTR.
... The implication is that alarm fatigue is reduced as a result. [6][7][8][9][10][11][12] At a broader level, however, cultural and sociotechnical issues also play a part in how alarms are viewed, and little is known about these issues. In theory, knowledge supports that over time, clinicians will increasingly attend to true alarms as the false alarm rate goes down. ...
... Led by a multidisciplinary CVSICU Alarm Management Team (AMT), which included CVSICU nursing staff, a CVSICU physician, a human factors engineer, and a nursing administration leader who chairs the hospital's Alarm Committee, the project was intended to improve the unit's culture of alarm safety by implementing a bundled set of published best practices related to cardiac monitor alarm reduction improvements. [20][21][22][23][24][25][26] To determine appropriate interventions to include in the bundled set of alarm reduction interventions, several preliminary steps were performed. First, CVSICU nurse volunteers completed an alarm perception survey. ...
Background Alarm fatigue in the ICU setting has been well documented in the literature. The ICU's high-intensity environment requires staff's vigilant attention, and distraction from false and non-actionable alarms pulls staff away from important tasks, creates dissatisfaction, and is a potential patient safety risk if alarms are missed or ignored. This project was intended to improve patient safety by optimizing alarm systems in a cardiovascular surgical intensive care unit (CVSICU). Specific aims were to examine nurses' attitudes toward clinical alarm signals, assess nurses' ability to discriminate audible alarm signals, and implement a bundled set of best practices for monitor alarm reduction without undermining patient safety. Methods CVSICU nurses completed an alarm perception survey and participated in alarm discriminability testing. Nurse survey data and baseline monitor alarm data were used to select targeted alarm reduction interventions, which were progressively phased in. Monitor alarm data and cardiorespiratory event data were trended over one year. Results Five of the most frequent CVSICU monitor alarm types—pulse oximetry, heart rate, systolic and diastolic blood pressure, pulse oximetry sensor, and ventricular tachycardia > 2—were targeted. After implementation, there was a 61% reduction in average alarms per monitored bed and a downward trend in cardiorespiratory events. Conclusion To reduce alarm fatigue it is important to decrease alarm burden through targeted interventions. Methods to reduce non-actionable alarms include adding short delays to allow alarm self-correction, adjusting default alarm threshold limits, providing alarm notification through a secondary device, and teaching staff to optimize alarm settings for individual patients.
... For example, the number of deaths associated with alarm-related events led to a national summit in the United States in 2011 and the Joint Commission (2013) issued a "Sentinel Event Alert" with strategic recommendations for a "frequent and persis-tent" problem. Since then, a raft of work has addressed the problem of overalarming to reduce "alarm fatigue" (see Cvach, 2012;Welch, 2011;Whalen et al., 2014). ...
Article
Full-text available
Given the ease with which the diverse array of environmental sounds can be understood, the difficulties encountered in using auditory alarm signals on medical devices are surprising. In two experiments, with nonclinical participants, alarm sets which relied on similarities to environmental sounds (concrete alarms, such as a heartbeat sound to indicate "check cardiovascular function") were compared to alarms using abstract tones to represent functions on medical devices. The extent to which alarms were acoustically diverse was also examined: alarm sets were either acoustically different or acoustically similar within each set. In Experiment 1, concrete alarm sets, which were also acoustically different, were learned more quickly than abstract alarms which were acoustically similar. Importantly, the abstract similar alarms were devised using guidelines from the current global medical device standard (International Electrotechnical Commission 60601-1-8, 2012). Experiment 2 replicated these findings. In addition, eye tracking data showed that participants were most likely to fixate first on the correct medical devices in an operating theater scene when presented with concrete acoustically different alarms using real world sounds. A new set of alarms which are related to environmental sounds and differ acoustically have therefore been proposed as a replacement for the current medical device standard. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
... Alarm fatigue is a well acknowledged phenomenon within the hospital environment that has stemmed from the prolific growth of technological support from medical devices, especially within the critical care environment, with such devices generating frequent and often false alarms (Cvach, 2012;Solet and Barach, 2012). Repeated exposure to a high frequency of audible alarms, from various devices has resulted in nurses becoming desensitised to alarms from medical devices, causing disengagement with alarm systems with alarms being turned off, silenced, ignored or responded to in an untimely manner, negating the effect of the true alarm (Cvach, 2012;Whalen et al., 2014). Critical care departments adopting CIDCs for the purpose of managing continuous intravenous insulin infusions need to consider and appropriately manage alarm fatigue within their department to ensure that alarms from CIDCs are responded to in a timely and appropriate manner to avoid adverse patient outcomes, such as hypoglycaemia and hyperglycaemia, which Please cite this article in press as: Higgs YICCN-2470;No. of Pages 8 Computerised insulin dosing calculators for the management of continuous insulin 7 are preventable when notification alarms are addressed appropriately. ...
Article
BACKGROUND: A number of insulin infusion algorithms, with varying methods and effects, have been developed to guide the management of postoperative hyperglycemia in critically ill patients.
... Similarly, patient/family experience was not optimally measured over the course of this work. Anecdotal experience suggests that the alarm notification reduction has a positive impact on patients and families, as has been previously described, 27 but there is not quantifiable evidence to support this aspect of the work. ...
Article
Background10 The Joint Commission identified inpatient alarm reduction as an opportunity to improve patient safety; enhance patient, family and nursing satisfaction; and optimise workflow. We used quality improvement (QI) methods to safely decrease non-actionable alarm notifications to bedside providers. Methods In a paediatric tertiary care centre, we convened a multidisciplinary team to address alarm notifications in our acute care cardiology unit. Alarm notification was defined as any alert to bedside providers for each patient-triggered monitor alarm. Our aim was to decrease alarm notifications per monitored bed per day by 60%. Plan-Do-Study-Act testing cycles included updating notification technology, establishing alarm logic and modifying bedside workflow processes, including silencing the volume on all bedside monitors. Our secondary outcome measure was nursing satisfaction. Balancing safety measures included floor to intensive care unit transfers and patient acuity level. Results At baseline, there was an average of 71 initial alarm notifications per monitored bed per day. Over a 3.5-year improvement period (2014–2017), the rate decreased by 68% to 22 initial alarm notifications per monitored bed per day. The proportion of initial to total alarm notifications remained stable, decreasing slightly from 51% to 40%. There was a significant improvement in subjective nursing satisfaction. At baseline, 32% of nurses agreed they were able to respond to alarms appropriately and quickly. Following interventions, agreement increased to 76% (p<0.001). We sustained these improvements over a year without a change in monitored balancing measures. Conclusion We successfully reduced alarm notifications while preserving patient safety over a 4-year period in a complex paediatric patient population using technological advances and QI methodology. Continued efforts are needed to further optimise monitor use across paediatric hospital units.
... It has been observed that ECG alarm frequency can be reduced by 50% when the high heartrate parameter is increased from 120 to 130 beats per minute [28]. Without causing harming, an 89% reduction in ECG alarms was also observed when heart-rate parameters were slightly widened [29]. Another suggestion is to adjust alarm limits to match meaningful changes in patient status, and using multi-parametric algorithms to identify true critical changes or trends [7]. ...
... Alarm yönetimi ile ilgili yapılan çalışmalarda; akıllı alarm sistemlerinin kullanılması, alarm limitlerinin hastanın klinik durumuna göre ayarlanması, elektrokardiyografi (EKG) elektrotları yerleştirilmeden önce derinin uygun şekilde hazırlanması ve elektrotların günlük olarak değiştirilmesi ile alarm sayısının önemli derecede azaldığı belirtilmektedir (3,19,(35)(36)(37) . Oksijen satürasyonu alarm limitlerine yönelik retrospektif bir çalışmada, oksijen satürasyonu alarm üst limitinin %90'dan %88'e düşürülmesinin toplam alarm sayısını %45 oranında azalttığı belirtilmektedir (21) . ...
... However, if the alarms are not managed consistently by all team members, the alarms turn into noise and may go unnoticed. Previous studies have mentioned that all interventions employees try to implement to prevent device-induced noise are those suggested in previous studies (Sendelbach et al., 2015;Whalen et al., 2014). It is clear that strategies for the effective management of alarms will be effective in preventing noise, as well. ...
Objectives: This study aimed to explore healthcare providers’ perceptions of noise in the intensive care unit (ICU). Design: A qualitative exploratory study was conducted using group interviews. Setting: The setting comprised a total of 15 participants (five physicians and ten registered nurses) working in an 18-bed medical surgical ICU at a teaching hospital in Istanbul, Turkey. Semi-structured questions were formulated and used in focus group interviews, after which the recorded interviews were transcribed by the researchers. Thematic analysis was used to identify significant statements and initial codes. Findings: Four themes were identified: the meaning of noise, sources of noise, effects of noise, and prevention and management of noise. It was found that noise was an inevitable feature of the ICU. The most common sources of noise were human-induced. It was also determined that device-induced noise, such as alarms, did not produce a lot of noise; however, when staff were late in responding, the sound transformed into noise. Furthermore, it was observed that efforts to decrease noise levels taken by ICU staff had only a momentary effect, changing nothing in the long term because the entire team failed to implement any initiatives consistently. The majority of nurses stated that they were now becoming insensitive to the noise due to the constant exposure to device-induced noise. Conclusion: The data obtained from this study showed that especially human-induced noise in the ICU threatened healthcare providers’ cognitive task functions, concentration, and job performance, impaired communication, and negatively affected patient safety. In addition, it was determined that any precautions taken to reduce noise were not fully effective. A team approach should be used in managing noise in ICUs with better awareness.
... Current approaches to addressing alarm annoyance focus on a variety of solutions. Some attempt to reduce the overall number of alarms by reconfiguring alarm acuity (Graham and Cvach, 2010;Whalen et al., 2014), widening parameters (Graham and Cvach, 2010) or discontinuing monitoring for certain low-risk populations (Dandoy et al., 2014). Others explore better managing the signals by adding secondary notifications (Cvach et al., 2014) and/or adding delays before sounding (Cvach et al., 2014;Taenzer et al., 2010). ...
Article
Full-text available
Auditory alarms offer great potential for facilitating human-computer interactions in complex, rapidly changing environments. They are particularly useful in medical settings, where in theory they should afford communication in emergency rooms, operating theatres, and hospitals around the world. Unfortunately, the sounds typically used in these devices are problematic, and researchers have documented numerous shortcomings. Their ubiquity means that even incremental improvements can have significant benefits for patient care. However, solutions have proven challenging for multiple reasons—including issues of backward compatibility inherent in changing any standard. Here we present a series of three experiments showing that manipulations to one specific, understudied property can significantly lower alarm annoyance without harming learning or memory—while preserving an alarm's melodic and rhythmic structure. These results suggest promising new directions for improving the hospital's soundscape, where evidence of problems related to sound are increasingly recognized as affecting medical outcomes as well as physician well-being.
... Practical applications of this work indicate that designing for trustable signaling systems may be more important for FP systems. This may be particularly important with regard to the recent changes made to hospital physiological alarming thresholds, which were made more conservative (i.e., MP) to combat excessive false alarms leading to alarm-fatigue (Whalen et al., 2014). Designers and practitioners may want to consider that adjusting threshold settings to be more conservative can garner different subjective evaluations toward the system, which may not be related to system trust. ...
Conference Paper
Full-text available
Research suggests that signaling system false alarms tend to affect operator compliance, whereas misses tend to affect operator reliance. Conceptually, false alarms and misses affect compliance and reliance via independent cognitive processes, assumed to be two types of trust. The purpose of this study was to test for these underlying processes using a subjective estimate of trust. Method: Using a sample of 44 college students , we tested for trust as a mediator between reliability (90%, 60%) and reliance, compliance, and response rate, for a false alarm prone (FP) system and a miss prone (MP) system. Results: As predicted, trust mediated the relationships between reliability and signal compliance and response rate, but only for the FP system. Additionally, the MP system more directly affected reliance, whereas the FP system more directly affected compliance. Applications of this work indicate that designing for trustable signaling systems may be more important for FP systems.
Article
BACKGROUND: The Joint Commission's 2014 National Patient Safety Goals required hospitals to evaluate alarm safety in 2014-2015 and implement alarm safety policies. OBJECTIVE: The aim of this study was to assess common alarm management safety factors in our 187-bed community hospital. METHODS: Two weeks' worth of IV pump report data was evaluated to characterize 33 IV pump alarm types. Hospital and IV pump noise was measured, and an alarm management nurse survey was conducted. RESULTS: There were 8731 total IV pump alarms/alerts (24-hour mean, 623.6) across 6 units. The 2-minute idle alarm accounted for 32.4% of all total IV alarms/alerts, suggestive of high levels of nurse multitasking and nurse work interruptions. IV pump volumes contributed to overall hospital noise. Survey data identified patient units and alarm safety practices needing additional support. CONCLUSIONS: Characterization of IV pump alarms/alerts is an emerging area of scientific inquiry. Findings indicate the need for organizations to evaluate alarm burden and alarm management safety practices to reduce alarm fatigue risks.
Article
Objectives: To investigate the effectiveness of computerised insulin dosing calculators for the management of continuous insulin infusions in adult patients who underwent cardiac surgery. Method: A systematic review was conducted. The CINAHL, MEDLINE and Cochrane databases were searched for primary studies that compared a computerised insulin dosing calculator to a paper protocol. The main outcome measures were mean Blood Glucose Level (BGL), time to achieve BGL target range, time spent within BGL target range, the incidence of hyperglycaemia and the incidence of hypoglycaemia. Results: Five studies were included in the final review. Pooled data demonstrated significant improvements in mean BGL (MD -14.24, 95% CI -26.93 to -1.55), p=0.03 and significantly lower rates of hypoglycaemia (OR 0.038, 95% CI: 0.16-0.90), p=0.03 amongst the computer calculator groups in comparison to the paper protocol groups. No significant difference in the incidence of severe hypoglycaemia was demonstrated (OR 0.21, 95% CI 0.02-1.79), p=0.15. No difference was found in time (hours) to reach target blood glucose range (MD -1.47, 95% CI -3.75 to 0.81), p=0.21. Conclusion: There is some evidence to support the use of computerised insulin dosing calculators for insulin infusion management within critical care environments.
Article
There has been a high rate of false alarms for the critical electrocardiogram (ECG) arrhythmia events in intensive care units (ICUs), from which the 'crying-wolf' syndrome may be resulted and patient safety may be jeopardized. This article presents an algorithm to reduce false critical arrhythmia alarms using arterial blood pressure (ABP) and/or photoplethysmogram (PPG) waveform features. We established long duration reference alarm datasets which consist of 573 ICU waveform-alarm records (283 for development set and 290 for test set) with total length of 551 patent days. Each record has continuous recordings of ECGs, ABP and/or PPG signals and contains one or multiple critical ECG alarms. The average length of a record is 23 h. There are totally 2408 critical ECG alarms (1414 in the development set and 994 in the test set), each of which was manually annotated by experts. The algorithm extracts ABP/PPG pulse features on a beat-by-beat basis. For each pulse, five event feature indicators (EFIs), which correspond to the five critical ECG alarms, are generated. At the time of a critical ECG alarm, the corresponding EFI values of those ABP/PPG pulses around the alarm time are checked for adjudicating (accept/reject) this alarm. The algorithm retains all (100%) the true alarms and significantly reduces the false alarms. Our results suggest that the algorithm is effective and practical on account of its real-time dynamic processing mechanism and computational efficiency.
Article
Background Arrhythmias are a common complication in pregnant women with heart disease. While continuous electrocardiographic monitoring is a useful tool for diagnosis, it also has significant associated costs, and identifying which pregnant women are most likely to benefit from monitoring is an important goal. Methods This is a retrospective observational study of pregnant adult women with heart disease cared for at an academic medical center between 2016 and 2020. Clinical information and ambulatory and inpatient monitoring results were abstracted from the electronic health record and descriptive statistics and T-tests were used to characterize the population. Results A total of 258 pregnancies in 202 unique women were included. The most common type of cardiovascular disease was congenital heart disease (56.6%), followed by cardiomyopathy (11.2%). An ambulatory monitor was ordered in 26.7% of pregnancies in the antepartum period, and 26.1% of these had clinically significant findings. 46.4% of monitors resulted in a clinical management change, with the most common changes being no recommendation for intrapartum electrocardiographic monitoring (20.3%) and starting a new medication (14.5%). Continuous electrocardiographic monitoring was used in 54.8% of deliveries, and detected a significant arrhythmia in only 2 cases (0.1%). Conclusions A symptom driven protocol for ambulatory monitoring in pregnancy yields abnormal findings in a significant proportion of patients, and nearly half trigger a change in clinical management. Intrapartum electrocardiographic monitoring has a low yield, with a significant arrhythmia detected in less than 1% of pregnancies in this cohort.
Article
Background: The purpose of this quality improvement project was to develop, implement, and assess the effects of an alarm management policy and educational program on nurses' perceptions and practices of alarm management in an acute care hospital. Method: Nurses from an acute care hospital in the southeastern United States attended a mandatory alarm management education program. The hospital implemented the evidence-based alarm management education to achieve the NPSG.06.01.01: Alarm Management. Pre- and posttests were administered to evaluate the education and the changes in nurses' perceptions and practices of clinical alarms. Results: A total of 417 nurses received the educational intervention. All participants completed the pretest, and 215 (51%) completed the voluntary posttest. Significant improvements were made in alarm perceptions and practices. Nurses suggested unit-specific alarm education, improved staffing, and updated equipment. Conclusion: Findings support the benefits of continued education in alarm management for nurses. Bedside nurses are a critical member of a multidisciplinary alarm management team because they are at the forefront of patient safety and most at risk for experiencing alarm fatigue. J Contin Educ Nurs. 2018;49(5):207-215.
Article
Purpose: Performance of ECG beat detectors is traditionally assessed on long intervals (e.g.: 30min), but only incorrect detections within a short interval (e.g.: 10s) may cause incorrect (i.e., missed+false) heart rate limit alarms (tachycardia and bradycardia). We propose a novel performance metric based on distribution of incorrect beat detection over a short interval and assess its relationship with incorrect heart rate limit alarm rates. Basic procedures: Six ECG beat detectors were assessed using performance metrics over long interval (sensitivity and positive predictive value over 30min) and short interval (Area Under empirical cumulative distribution function (AUecdf) for short interval (i.e., 10s) sensitivity and positive predictive value) on two ECG databases. False heart rate limit and asystole alarm rates calculated using a third ECG database were then correlated (Spearman's rank correlation) with each calculated performance metric. Main findings: False alarm rates correlated with sensitivity calculated on long interval (i.e., 30min) (ρ=-0.8 and p<0.05) and AUecdf for sensitivity (ρ=0.9 and p<0.05) in all assessed ECG databases. Sensitivity over 30min grouped the two detectors with lowest false alarm rates while AUecdf for sensitivity provided further information to identify the two beat detectors with highest false alarm rates as well which was inseparable with sensitivity over 30min. Principal conclusions: Short interval performance metrics can provide insights on the potential of a beat detector to generate incorrect heart rate limit alarms.
Article
Background: Sedation and analgesia have an important impact on the outcome of patients treated with mechanical ventilation. International guidelines recommend use of sedation protocols to ensure best patient care. Objective: To determine the sedation practice of intensive care nurses weaning adults from mechanical ventilation. Methods: A cross-sectional survey with a self-administered questionnaire was used to determine sedation practices of Flemish critical care nurses during weaning. Consensus on content validity was achieved through a Delphi procedure among experts. Data were collected during the 32nd Annual Congress of the Flemish Society of Critical Care Nurses in Ghent, Belgium, December 2014. Results: A total of 342 nurses were included in the study. Of these, 43.7% had a sedation protocol in their unit that was used by 61.8% of the respondents. Sedation protocols were more often available (P < .001) in academic hospitals (72%) than in general hospitals (41.5%). Sedatives were administered via continuous infusion with bolus doses if needed (81%). Level of sedation was assessed every 2 hours (56%), mostly via the Richmond Agitation-Sedation Scale (59.1%). Daily interruption of sedation was used by 16.5% of respondents. The biggest barriers to daily interruption were patient comfort (49.4%) and fear of respiratory worsening (46.6%). Conclusions: A considerable discrepancy exists between international recommendations and actual sedation practices. Standardization of sedation practices across different institutions on a regional and national level may improve the quality of care.
Article
Background: Endotracheal and nasogastric tubes are recognized risk factors for nosocomial sinusitis. The extent to which these tubes affect the overall incidence of nosocomial sinusitis in acute care hospitals is unknown. Objective: To use data for 2008 through 2013 from the Nationwide Inpatient Sample database to compare the incidence of sinusitis in patients with nasogastric tubes with that in patients with an endotracheal tube alone or with both an endotracheal tube and a nasogastric tube. Methods: Patients' data with any of the following International Classification of Disease, Ninth Revision, Clinical Modification codes were abstracted from the database: (1) 96.6, enteral infusion of concentrated nutritional substances; (2) 96.07, insertion of other (naso-)gastric tube; or (3) 96.04, insertion of an endotracheal tube. Sinusitis was defined by the appropriate codes. Weighted and unweighted frequencies and weighted percentages were calculated, categorical comparisons were made by χ2 test, and logistic regression was used to examine odds of sinusitis development by tube type. Results: Of 1 141 632 included cases, most (68.57%) had an endotracheal tube only, 23.02% had a nasogastric tube only, and 8.41% had both types of tubes. Sinusitis was present in 0.15% of the sample. Compared with patients with only a nasogastric tube, the risk for sinusitis was 41% greater in patients with an endotracheal tube and 200% greater in patients with both tubes. Conclusion: Despite the low incidence of sinusitis, a significant association exists between sinusitis and the presence of an endotracheal tube, especially when a nasogastric tube is also present.
Article
This chapter is a review of studies that have examined false arrhythmia alarms during in-hospital electrocardiographic (ECG) monitoring in the intensive care unit. In addition, we describe an annotation effort being conducted at the UCSF School of Nursing, Center for Physiologic Research designed to improve algorithms for lethal arrhythmias (i.e., asystole, ventricular fibrillation, and ventricular tachycardia). Background: Alarm fatigue is a serious patient safety hazard among hospitalized patients. Data from the past five years, showed that alarm fatigue was responsible for over 650 deaths, which is likely lower than the actual number due to under-reporting. Arrhythmia alarms are a common source of false alarms and 90% are false. While clinical scientists have implemented a number of interventions to reduce these types of alarms (e.g., customized alarm settings; daily skin electrode changes; disposable vs. non-disposable lead wires; and education), only minor improvements have been made. This is likely as these interventions do not address the primary problem of false arrhythmia alarms, namely deficient and outdated arrhythmia algorithms. In this chapter we will describe a number of ECG features associated with false arrhythmia alarms. In addition, we briefly discuss an annotation effort our group has undertaken to improve lethal arrhythmia algorithms.
Article
Background: In 2018, The Joint Commission identified false telemetry alarms as a significant technology hazard placing patients at risk of injury. Reasons include poor skin preparation when applying electrodes and improper placement of electrodes. Objectives: The purpose of this quality improvement project was to determine if changing electrocardiogram electrodes daily would decrease the frequency of nuisance alarms. Methods: Study design was quantitative/comparative on all patients receiving telemetry monitoring on a 36-bed adult inpatient cardiac telemetry unit. Data collection occurred for 14 days before the intervention and 14 days during the intervention of daily electrode change. Comparison analysis determined if frequency of alarms decreased after the intervention with daily electrode change. Results: Postintervention data showed a 74.15% reduction in telemetry alarms following implementation of a daily electrode change. Discussion: Daily electrocardiogram electrode changes may be an effective strategy for reducing nuisance alarms on telemetry units. Outcomes can be used in conjunction with existing evidence to drive current practice.
Article
New-onset atrial fibrillation (NOAF) during acute myocardial infarction (AMI) has significant consequences but is often misdiagnosed. The aim of the study was to evaluate predictors of NOAF throughout different phases of AMI. Patients with AMI admitted to a tertiary medical center were analyzed. Exclusion criteria were preexisting AF, AMI onset ≥24 hours prior to admission, in-hospital death, significant valvular disease, and in-hospital coronary artery bypass graft. Study population were AMI without-NOAF, early-AF (AF terminated within 24 hours of admission), and late-AF (beyond the first 24 hours). Overall 5946 patients were included, age: 64.8 ±14.8 years; 30% women. The incidence of NOAF was 4.6%: 1.6% early-AF, and 3% late-AF. Patients with NOAF comprised greater rate of women, cardiovascular risk-factors burden, severe left ventricular-dysfunction, pulmonary hypertension, valvular disorders, and left atrial enlargement compared with patients without-NOAF. Non-ST-elevation myocardial infarction and inferior-ST-elevation myocardial infarction (STEMI) were significantly more prevalent among early-AF group, while anterior-STEMI, in late-AF. The final multivariate models showed c-statistics of 0.73 and 0.76 for the prediction of new-onset early-AF and late-AF, respectively. In conclusion, there are different clinical predictors of early- versus late-NOAF. The study points out “high risk” AMI population for more meticulous heart rate monitoring for NOAF.
Article
Background: Patients with both true and false arrhythmia alarms pose a challenge because true alarms might be buried among a large number of false alarms, leading to missed true events. Objective: To determine (1) the frequency of patients with both true and false arrhythmia alarms; (2) patient, clinical, and electrocardiographic characteristics associated with both true and false alarms; and (3) the frequency and types of true and false arrhythmia alarms. Methods: This was a secondary analysis using data from an alarm study conducted at a tertiary academic medical center. Results: Of 461 intensive care unit patients, 211 (46%) had no arrhythmia alarms, 12 (3%) had only true alarms, 167 (36%) had only false alarms, and 71 (15%) had both true and false alarms. Ventricular pacemaker, altered mental status, mechanical ventilation, and cardiac intensive care unit admission were present more often in patients with both true and false alarms than among other patients (P < .001). Intensive care unit stays were longer in patients with only false alarms (mean [SD], 106 [162] hours) and those with both true and false alarms (mean [SD], 208 [333] hours) than in other patients. Accelerated ventricular rhythm was the most common alarm type (37%). Conclusions: An awareness of factors associated with arrhythmia alarms might aid in developing solutions to decrease alarm fatigue. To improve detection of true alarms, further research is needed to build and test electrocardiographic algorithms that adjust for clinical and electrocardiographic characteristics associated with false alarms.
Article
Introduction : In critical care units, improper alarm settings for bedside monitoring systems promotes numerous alarms and may lead to nurse fatigue. Purpose : Achieve an integrative review of the literature to identify the factors that influence the nurse in her decision to set and modulate the alarm parameters of bedside monitoring systems in the intensive care unit. Method : An integrative review of the literature according to the five steps of the Whittemore and Knafl method was carried out from the literature related to the field of critical care. Results : The factors related to the nurse’s decision to set or modulate the alarm parameters of the monitoring systems are divided into two themes : personal factors and contextual factors. Discussion : Certain factors identified in this integrative review were also identified as elements that contribute to the clinical surveillance process carried out by expert nurses in a critical care context. Conclusion : The results of this study suggest the need to focus empirically on the factors influencing the nurse’s decision to adjust and modulate alarm parameters in critical care monitoring systems.
Article
Background: Cardiac telemetry nuisance alarms due to leads off and poor signal increase staff workflow interruptions, decrease staff trust in technology, and can compromise patient safety. Local problem: Interventions were directed at reducing nuisance alarms on a 32-bed, non-intensive care - a cardiac telemetry unit. Methods: A nursing staff education module with evidence-based practices for reducing nuisance alarms, a daily care protocol for patients on cardiac telemetry monitoring, and daily audits of protocol adherence were implemented. Results: Staff pre- and posttest comparisons on their knowledge relating to nuisance alarms and the evidence-based protocol demonstrated a significant mean increase of 3.02 (95% CI, 2.55-3.48). Daily audits for 7 weeks demonstrated an average of 58.46% staff adherence. Telemetry technician call volume reduction was 16% postimplementation, while nuisance alarms were not reduced significantly. Conclusions: This rapid-cycle, quality improvement process resulted in minimal reduction in nuisance alarms but improved staff awareness of the issue and reduced workflow interruptions.
Article
Background: In hospitalized patients with left ventricular assist device (LVAD), electrical interference and low amplitude QRS complexes are common, which could impact the accuracy of electrocardiographic (ECG) arrhythmia detection and create technical alarms. This could contribute to provider alarm fatigue and threaten patient safety. Objectives: We examined three LVAD patients in the cardiac intensive care unit (ICU) to determine: 1) the frequency and accuracy of audible arrhythmia alarms; 2) occurrence rates of technical alarms; and 3) alarm burden (# alarms/hour of monitoring) METHODS: Secondary analysis. Results: During 593 h, there were 549 audible arrhythmia alarms and 98% were false. There were 25,232 technical alarms and 93% were for artifact, which was configured as an inaudible text alert. Conclusion: False-arrhythmia and technical alarms are frequent in LVAD patients. Future studies are needed to identify both clinical and algorithm-based strategies to improve arrhythmia detection and reduce technical alarms in LVAD patients.
Article
Full-text available
Reliance on physiological monitors to continuously "watch" patients and to alert the nurse when a serious rhythm problem occurs is standard practice on monitored units. Alarms are intended to alert clinicians to deviations from a predetermined "normal" status. However, alarm fatigue may occur when the sheer number of monitor alarms overwhelms clinicians, possibly leading to alarms being disabled, silenced, or ignored. Excessive numbers of monitor alarms and fear that nurses have become desensitized to these alarms was the impetus for a unit-based quality improvement project. Small tests of change to improve alarm management were conducted on a medical progressive care unit. The types and frequency of monitor alarms in the unit were assessed. Nurses were trained to individualize patients' alarm parameter limits and levels. Monitor software was modified to promote audibility of critical alarms. Critical monitor alarms were reduced 43% from baseline data. The reduction of alarms could be attributed to adjustment of monitor alarm defaults, careful assessment and customization of monitor alarm parameter limits and levels, and implementation of an interdisciplinary monitor policy. Although alarms are important and sometimes life-saving, they can compromise patients' safety if ignored. This unit-based quality improvement initiative was beneficial as a starting point for revamping alarm management throughout the institution.
Article
Although devices to monitor various aspects of a patient in the hospital are intended to improve safety, sometimes they cause harm. The number of conditions and therapeutics to be monitored, “alarm fatigue” caused by the large number of alarms, and a lack of commitment by hospital staff all can lead to dire consequences.The situation is not new, but it is enough of a concern that the Joint Commission in April issued a Sentinel Event Alert for 98 alarm-related incidents between January 2009 and June 2012. Of the events, 80 resulted in death, 13 in permanent loss of function, and 5 in unexpected additional care or extended stays. The commission believes these sentinel events represent less than 10% of the actual alarm-related harms that occurred in hospitals.
Article
For the past several years ECRI Institute has published a list of Top Ten Health Technology Hazards. This list is based on ECRI's extensive research in health technology safety and on data provided to its problemreporting systems. For every year that the Top Ten list has been published, Alarm Hazards have been at or near the top of the list. Improving alarm safety requires a systematic review of a hospital's alarm-based technologies and analysis of alarm management policies like alarm escalation strategies and staffing patterns. It also requires careful selection of alarm setting criteria for each clinical care area. This article will overview the clinical alarm problems that have been identified through ECRI Institute's research and analysis of various problem reporting databases, including those operated by ECRI Institute. It will also highlight suggestions for improvement, particularly from a technology design and technology management perspective.
Article
The number of false high alarms in the hospital setting remains a serious problem. False alarms have desensitized care providers and, at times, have led to dire consequences for patients. Efforts by both industry and clinicians are beginning to address this situation in collaborative approaches. Research is needed to establish an evidence base around issues such as which patients need to be monitored, and what the threshold settings and delay settings should be on devices. Initial and ongoing education needs to be considered for any new medical device, and be included in the hospital's annual budget.
Article
During the study period, surveys were administered for 182 patients. The response rate was 73% for admission surveys and 74% for the discharge surveys, yielding a final sample of 100 patients for whom we had complete admission and discharge survey data. The mean patient age was 66 years; 53% of the patients were women; and 18% had do-not-resuscitate orders (Table). The patients spent an average of 2.6 days on telemetry monitoring. The 3 most common admitting diagnoses were gastrointestinal bleeding (19%), renal failure (17%), and pneumonia (11%). Only 11 patients in our cohort met AHA class I indications for the use of telemetry. Most patients (57%) had no cardiac history. The initial rhythm for most patients was normal sinus rhythm or sinus tachycardia, and the most common telemetry events were sinus bradycardia, sinus tachycardia, and premature ventricular contractions. Four patients developed new atrial fibrillation or flutter. Nineteen patients had management changes in response to telemetry events. Because more than 1 intervention was possible per patient, 9 patients underwent diagnostic testing, 8 had medications changed, 7 had intravenous fluids administered, and 2 were transferred to the intensive care unit.
Article
Alarm fatigue is a national problem and the number one medical device technology hazard in 2012. The problem of alarm desensitization is multifaceted and related to a high false alarm rate, poor positive predictive value, lack of alarm standardization, and the number of alarming medical devices in hospitals today. This integrative review synthesizes research and non-research findings published between 1/1/2000 and 10/1/2011 using The Johns Hopkins Nursing Evidence-Based Practice model. Seventy-two articles were included. Research evidence was organized into five main themes: excessive alarms and effects on staff; nurse's response to alarms; alarm sounds and audibility; technology to reduce false alarms; and alarm notification systems. Non-research evidence was divided into two main themes: strategies to reduce alarm desensitization, and alarm priority and notification systems. Evidence-based practice recommendations and gaps in research are summarized.
Article
It has been known to the public that high frequency of false and/or unnecessary alarms from patient monitoring devices causes "alarm fatigue" in critical care. But little is known about the impact to care on the less acute patients located outside the critical care areas, such as the traditional medical/surgical (med/surg) floor. As part of a larger population management study, we initiated continuous physiological monitoring to 79 beds of floor patients in a community hospital. In order to qualify the patient monitoring alarm load for subacute medical and surgical floor patients, we assessed alarm data from April 2009 to January 2010. A standard critical care monitoring system (Philips IntelliVue MP-5 and Telemetry) was installed and set to the default alarm limits. All waveform data available for the patient (typically ECG, RESP, PPG at 125hz 8 bit), all alarm conditions declared by the monitoring system, and 1 minute parameter trend data were saved to disk every 8 hours for all patients. A monitoring care protocol was created to determine whether the patient was monitored via the hardwired bedside or wirelessly via telemetry. Alarms were not announced on the care unit but instead notifications were the responsibility of remote telehealth center personnel. We retrospectively evaluated the frequency of alarms over specific physiologic thresholds (n= 4104 patients) and conducted adjudication of all alarms based on a smaller sampling (n=30 patients). For all patients, the average hours of monitoring per patient were 16.5 hours with a standard deviation (s) of 8.3 hours and a median of 22 hours. The average number of alarms (all severities) per patient was 69.7 (s =90.3, median =28) alarms. When this is adjusted to the duration of monitoring, the average per patient, per day rate was 95.6 (s =124.2, median =34.2) alarms. The adjudicated sample (n=30 patients) resulted in 34% of critical alarms (lethal arrhythmias, extreme high or low heart rate [HR], extreme desaturation, apnea) being true and 63% of the high priority alarms (high or low HR, high or low RR, Low SpO(2), pause, Missed Beat, Pair PVCs, Pacer Not Pace, Non Sustain VT, Irregular HR, Multiform) being true. Analysis of alarm history resulted in the ability to reduce the HR alarm load by more than 50% with a simple limit adjustment of high HR from 120 to 130 bpm and a 36% or 65% reduction in SpO(2) alarm load by reducing the SpO(2) limit from 90% to 85% or 80% respectively. 1) Standard critical care alarm limits appear be too sensitive for subacute care areas of the hospital. 2) For most patients these alarm limits do not create a significant alarm load; however, for a small number of patients they cause a significant alarm load. 3) Alarm loads can be controlled with alarm limit settings appropriate to the population. 4) Current technology for HR and SpO(2) appear suitable for continuous monitoring of this population.
Article
The goal of therapy for bradycardia or tachycardia is to rapidly identify and treat patients who are hemodynamically unstable or symptomatic due to the arrhythmia. Drugs or, when appropriate, pacing may be used to control unstable or symptomatic bradycardia. Cardioversion or drugs or both may be used to control unstable or symptomatic tachycardia. ACLS providers should closely monitor stable patients pending expert consultation and should be prepared to aggressively treat those with evidence of decompensation.
Article
Constant alarms can contribute to providers' failure to respond.
Article
This is the fourth in a series of articles from Planetree, an international nonprofit organization founded in 1978 that's "committed to improving medical care from the patient's perspective." For more information, go to www.planetree.org.
Article
Cardiac telemetry is widely used in hospitals, but it is expensive and labor-intensive. Therefore, it should be used only in those most likely to benefit. The authors review the available evidence and offer their recommendations.
Article
Non-intensive telemetry units are utilized for monitoring patients at risk for life-threatening dysrhythmias and sudden death. Physicians often use monitored beds for patients who might only require frequent nursing care. When 70% of the top 10 diseases admitted through the emergency department (ED) are clinically indicated for telemetry, hospitals with limited resources will be overwhelmed and admitted patients will be forced to wait in the ED. We examine the evidence behind admitting patients to telemetry. There is evidence for monitoring in patients admitted for implantable cardioverter-defibrillator firing, type II and complete atrio-ventricular block, prolonged QT interval with ventricular arrhythmia, decompensated heart failure, acute cerebrovascular event, acute coronary syndrome, and massive blood transfusion. Monitoring is beneficial for selected patients with syncope, gastrointestinal hemorrhage, atrial tachyarrhythmias, and uncorrected electrolyte abnormalities. Finally, telemetry is not indicated for patients requiring minor blood transfusion, low risk chest pain patients with normal electrocardiography, and stable patients receiving anticoagulation for pulmonary embolism.
2010 American Heart Association cardiopulmonary resuscitation and emergency cardiovascular care science.
  • Newmar
Alarm fatigue hazards: the sirens are calling.
  • Welch