Maria Cvach

Monitor Alarm Fatigue: An Integrative Review

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; nurses 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.

An evidence-based approach to fall risk assessment, prevention, and management: lessons learned.

Nurses at an academic medical institution undertook a fall safety initiative. Using an evidence-based approach, they created a risk stratification tool, developed a comprehensive protocol, investigated fall-prevention products and technologies, and piloted the protocol and products/technologies before the full implementation. This article describes their journey and lessons learned along the way, the most compelling of which is the need for a simple, guided, and time-efficient approach to implementing the best practices into clinical care.

The Johns Hopkins Fall Risk Assessment Tool: postimplementation evaluation.

IN OCTOBER 2003, The Johns Hopkins Fall Risk Assessment Tool was implemented throughout our organization. The evidence-based development of this tool was published previously in this journal.1 At the time, the decision was made to implement the tool on all adult clinical care units throughout the ho

Daily electrode change and effect on cardiac monitor alarms: an evidence-based practice approach.

Frequent monitor alarms are distracting and interfere with clinicians performing critical tasks. This article describes a quality improvement rapid-cycle change approach to explore the benefits of changing electrodes daily on the number of cardiac monitor alarms. Eight days of baseline and intervention data were compared for 2 adult acute care units. Average alarms per bed per day were reduced by 46% on both units. Daily electrocardiogram electrode change reduces the number of cardiac monitor alarms.

Technological Distractions (part 2): A Summary of Approaches to Manage Clinical Alarms With Intent to Reduce Alarm Fatigue

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.

Update to Practice Standards for Electrocardiographic Monitoring in Hospital Settings: A Scientific Statement From the American Heart Association

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.

Effect of Altering Alarm Settings: A Randomized Controlled Study

UNLABELLED Medical alarm signals are important for alerting clinicians to life-threatening conditions, but the high rate of false alarms can be problematic. Reduction in alarm signals may lead to increased staff responsiveness to alarms and create a quieter environment for patients. The effect of these changes on patient outcomes is uncertain. METHODS We conducted a pilot, prospective, randomized, controlled trial in the cardiac care unit (CCU) to test a study protocol and data collection instruments and to examine the differences in alarms between usual care and altered settings. Subjects were randomized daily to either standard or altered CCU alarm settings. Secondary outcomes included the number of clinically significant events (CSEs) detected, event-triggered interventions (ETIs), frequency of alarms per monitored bed, and patient complications. RESULTS Over the two-week study time frame, 22 unique patients were enrolled. There were 1,710 alarms over 163 hours of monitoring in the standard group and 1,165 alarms over 169 hours in the study group (P < 0.001). There were more CSEs detected (14 vs. 3) and ETIs (12 vs. 2) in the study group, but sample size was too small to determine efficacy. No cardiac arrests or adverse patient outcomes were observed in either group. All patients were discharged from the hospital. Study protocol and outcomes were feasible and lessons were learned. CONCLUSION This study demonstrated feasibility of a study protocol for conducting a randomized controlled trial to evaluate CSEs, ETIs, frequency of alarms, and adverse patient outcomes when altering default alarm settings. A longer study can be performed using a similar study design.

Technologic Distractions (part 1): Summary of Approaches to Manage Alert Quantity With Intent to Reduce Alert Fatigue and Suggestions for Alert Fatigue Metrics

Objective: To provide ICU clinicians with evidence-based guidance on tested interventions that reduce or prevent alert fatigue within clinical decision support systems. Design: Systematic review of PubMed, Embase, SCOPUS, and CINAHL for relevant literature from 1966 to February 2017. Patients: Focus on critically ill patients and included evaluations in other patient care settings, as well. Interventions: Identified interventions designed to reduce or prevent alert fatigue within clinical decision support systems. Measurements and Main Results: Study selection was based on one primary key question to identify effective interventions that attempted to reduce alert fatigue and three secondary key questions that covered the negative effects of alert fatigue, potential unintended consequences of efforts to reduce alert fatigue, and ideal alert quantity. Data were abstracted by two reviewers independently using a standardized abstraction tool. Surveys, meeting abstracts, “gray” literature, studies not available in English, and studies with non-original data were excluded. For the primary key question, articles were excluded if they did not provide a comparator as key question 1 was designed as a problem, intervention, comparison, and outcome question. We anticipated that reduction in alert fatigue, including the concept of desensitization may not be directly measured and thus considered interventions that reduced alert quantity as a surrogate marker for alert fatigue. Twenty-six articles met the inclusion criteria. Conclusion: Approaches for managing alert fatigue in the ICU are provided as a result of reviewing tested interventions that reduced alert quantity with the anticipated effect of reducing fatigue. Suggested alert management strategies include prioritizing alerts, developing sophisticated alerts, customizing commercially available alerts, and including end user opinion in alert selection. Alert fatigue itself is studied less frequently, as an outcome, and there is a need for more precise evaluation. Standardized metrics for alert fatigue is needed to advance the field. Suggestions for standardized metrics are provided in this document.

Managing clinical alarms: using data to drive change.

Too often clinicians are apathetic to alarms, thus they silence, disable, or ignore them. In fact, patients have been discovered unconscious and not breathing while leadsoff alarms went unnoticed.1 Failure to respond to alarm signals in a timely manner has led The Joint Commission (TJC) to introduce a new National Patient Safety Goal on alarm management beginning in 2014.2 Alarms are common on clinical units, but most are false, and these false alarms distract nurses from performing important work, making them immune to true alarms. Studies indicate that 85% to 99% of alarm signals generated by medical devices are false and/ or clinically insignificant, resulting in a phenomenon known as alarm fatigue.3-6 Alarm fatigue is the lack of response to an alarm due to excessive numbers, resulting in sensory overload and desensitization. From 2005 to the middle of 2010, 216 reported deaths have been linked to monitor alarm systems.1 ECRI (formally known as the Emergency Care and Research Institute), a nonprofit organization that uses applied scientific research in healthcare to establish best practices for improving patient care, lists alarm issues as the number one health technology device hazard for the past 2 years.7 The Association for the Advancement of Medical Instrumentation issued a challenge that by 2017 no patient will be harmed by adverse alarm events.8 While higher nurse staffing is associated with reduced hospital mortality, false alarms distract nurses and occupy their time with interventions that don’t benefit patients. Thus, these false alarms effectively reduce the value of increased nurse staffing. Hospitals are packed with an ever-growing number of medical devices, each one with its own alarm, and hospitals lack policies defining alarm accountability, as well as technologies to integrate and prioritize alarms. Because of the challenges stated above, TJC has created an alarm management goal (NPSG.06.01.01) aimed at improving clinical alarm system safety. This goal will be phased-in with two Elements of Performance (EP) being implemented by July 2014 and two EPs being implemented by 2016. The first 2 EPs address hospital leadership establishing alarm system safety as a hospital priority, as well as identifying the most important alarm signals to manage. EP 3 requires hospitals to establish alarm management policies and procedures for those alarms identified in EP 2, including appropriate settings for alarm signals; defining when alarm signals can be disabled; who can change alarm parameter settings; when alarms can be turned “off;” and who and how staff respond to alarm signals. The final EP indicates that hospital staff must be educated about the purpose and proper operation of alarm systems for which they’re responsible.9

The frequency of physiologic monitor alarms in a children's hospital

Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; Division of General Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; Division of Hospital Medicine, Lucile Packard Children’s Hospital Stanford, Palo Alto, California; Division of Critical Care, Children’s Hospital Los Angeles, Los Angeles, California; Department of Nursing, Johns Hopkins Hospital, Baltimore, Maryland; Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio.