Insights into the Problem of Alarm Fatigue with Physiologic Monitor Devices: A Comprehensive Observational Study of Consecutive Intensive Care Unit Patients

Abstract

PurposePhysiologic monitors are plagued with alarms that create a cacophony of sounds and visual alerts causing “alarm fatigue” which creates an unsafe patient environment because a life-threatening event may be missed in this milieu of sensory overload. Using a state-of-the-art technology acquisition infrastructure, all monitor data including 7 ECG leads, all pressure, SpO2, and respiration waveforms as well as user settings and alarms were stored on 461 adults treated in intensive care units. Using a well-defined alarm annotation protocol, nurse scientists with 95% inter-rater reliability annotated 12,671 arrhythmia alarms.ResultsA total of 2,558,760 unique alarms occurred in the 31-day study period: arrhythmia, 1,154,201; parameter, 612,927; technical, 791,632. There were 381,560 audible alarms for an audible alarm burden of 187/bed/day. 88.8% of the 12,671 annotated arrhythmia alarms were false positives. Conditions causing excessive alarms included inappropriate alarm settings, persistent atrial fibrillation, and non-actionable events such as PVC's and brief spikes in ST segments. Low amplitude QRS complexes in some, but not all available ECG leads caused undercounting and false arrhythmia alarms. Wide QRS complexes due to bundle branch block or ventricular pacemaker rhythm caused false alarms. 93% of the 168 true ventricular tachycardia alarms were not sustained long enough to warrant treatment.DiscussionThe excessive number of physiologic monitor alarms is a complex interplay of inappropriate user settings, patient conditions, and algorithm deficiencies. Device solutions should focus on use of all available ECG leads to identify non-artifact leads and leads with adequate QRS amplitude. Devices should provide prompts to aide in more appropriate tailoring of alarm settings to individual patients. Atrial fibrillation alarms should be limited to new onset and termination of the arrhythmia and delays for ST-segment and other parameter alarms should be configurable. Because computer devices are more reliable than humans, an opportunity exists to improve physiologic monitoring and reduce alarm fatigue.

Measurement of Physiological Monitor Alarm Accuracy and Clinical Relevance in Intensive Care Units

“…Four of the studies were conducted in pediatric populations 5,[20][21][22] and 7 were conducted in adult populations. [23][24][25][26][27][28][29] One study included both children and adults. 30 Additionally, in 1 study, 5 alarms in both a pediatric general care area and a pediatric ICU were annotated; for this review, we used only pediatric ICU data.…”

Research in Review: Driving Critical Care Practice Change

“…A study published in October 2014 by Drew et al 5 strengthens the level of evidence available to inform tailoring of alarms. In this observational study, all alarms and alarm settings from an electrocardiography (ECG) system and additional monitors (eg, arterial blood pressure, pulse oximeter) were collected from 461 patients in 31 days.…”

Optimisation of Electrode Placement for New Ambulatory ECG Monitoring Devices

“…As such, many false positive alarms in a clinical setting can be made attributable to low R-wave amplitude and in turn low signal to noise ratio [15]. In this study we have focused on determining the optimal placement of ECG electrodes for the recording of maximum R-wave amplitude.…”