Changes in Default Alarm Settings and Standard In-Service are Insufficient to Improve Alarm Fatigue in an Intensive Care Unit: A Pilot Project

Abstract

BackgroundClinical alarm systems safety is a national concern, specifically in intensive care units (ICUs) where alarm rates are known to be the highest. Interventional projects that examined the effect of changing default alarm settings on overall alarm rate and on clinicians’ attitudes and practices toward clinical alarms and alarm fatigue are scarce.ObjectiveTo examine if (1) a change in default alarm settings of the cardiac monitors and (2) in-service nursing education on cardiac monitor use in an ICU would result in reducing alarm rate and in improving nurses’ attitudes and practices toward clinical alarms.MethodsThis quality improvement project took place in a 20-bed transplant/cardiac ICU with a total of 39 nurses. We implemented a unit-wide change of default alarm settings involving 17 parameters of the cardiac monitors. All nurses received an in-service education on monitor use. Alarm data were collected from the audit log of the cardiac monitors 10 weeks before and 10 weeks after the change in monitors’ parameters. Nurses’ attitudes and practices toward clinical alarms were measured using the Healthcare Technology Foundation National Clinical Alarms Survey, pre- and postintervention.ResultsAlarm rate was 87.86 alarms/patient day (a total of 64,500 alarms) at the preintervention period compared to 59.18 alarms/patient day (49,319 alarms) postintervention (P=.01). At baseline, Arterial Blood Pressure (ABP), Pair Premature Ventricular Contractions (PVCs), and Peripheral Capillary Oxygen Saturation (SpO2) alarms were the highest. ABP and SpO2 alarms remained among the top three at the postproject period. Out of the 39 ICU nurses, 24 (62%) provided complete pre- and postproject survey questionnaires. Compared to the preintervention survey, no remarkable changes in the postproject period were reported in nurses’ attitudes. Themes in the narrative data were related to poor usability of cardiac monitors and the frequent alarms. The data showed great variation among nurses in terms of changing alarm parameters and frequency of replacing patients' electrodes. Despite the in-service, 50% (12/24) of the nurses specified their need for more training on cardiac monitors in the postproject period.ConclusionsChanging default alarm settings and standard in-service education on cardiac monitor use are insufficient to improve alarm systems safety. Alarm management in ICUs is very complex, involving alarm management practices by clinicians, availability of unit policies and procedures, unit layout, complexity and usability of monitoring devices, and adequacy of training on system use. The complexity of the newer monitoring systems requires urgent usability testing and multidimensional interventions to improve alarm systems safety and to attain the Joint Commission National Patient Safety Goal on alarm systems safety in critical care units.

Fatores que interferem na resposta dos enfermeiros na monitorização dos alarmes clínicos

“…These alarms are known as "nuisance" alarms. The study by Sowan et al showed that most nurses interviewed strongly agreed that "nuisance" alarms are frequent, interrupt the care provided to patients, and reduce the reliability of alarms (11). When alarms are considered that way, professionals might disconnect and silence them, or ignore the warning that is intended to make a safer environment.…”

“…When alarms are considered that way, professionals might disconnect and silence them, or ignore the warning that is intended to make a safer environment. Instead of creating a safer environment, a high number of "nuisance" alarms assumes the opposite effect, resulting in desensitization (3,11) . This problem assumes special attention regarding low-priority alarms.…”

“…Therefore, the duration of signals assumes an important influence; however, workload, severity of patients, and complexity of interventions might lead to other reaction/response strategies (3) . Both the design of devices' alarm systems and the level of knowledge of professionals contribute to the inappropriate setting of alarms, which justify effective and continuous training reinforced by the study by Sowan et al, in which 50% of nurses reported the need for training on cardiac monitors (11) . Although many alarm systems seem apparently easy, their functioning is not well understood by the staff.…”

“…Hospitals must have appropriate policies to ensure training of healthcare professionals in the correct use of devices and alarm systems. The design of intensive care units must be thought and structured in a way that alarms can always be heard by the staff (9,11) . Reduction of false alarms must result in a significant decrease in the frequency of alarms, with proportional increase in relevant clinical alarms.…”

Nurse Competence on Physiologic Monitors Use: Toward Eliminating Alarm Fatigue in Intensive Care Units

“…On the other hand, although some system-based alarm management strategies achieved success in alarm reduction [14, 15], in other studies this success was not complemented with improvements in alarm fatigue or nurses’ attitudes toward alarm safety [9, 10]. Nurses reported the need for more training on physiologic monitors [9, 10]. It seems that the complexity of modern IT-equipped physiologic monitors requires structured individualized training focused on developing specific skill sets to navigate monitors and manage alarms [11, 12].…”