The heuristics of nurse responsiveness to critical patient monitor and ventilator alarms in a private room neonatal intensive care unit

Abstract

AimAlarm fatigue is a well-recognized patient safety concern in intensive care settings. Decreased nurse responsiveness and slow response times to alarms are the potentially dangerous consequences of alarm fatigue. The aim of this study was to determine the factors that modulate nurse responsiveness to critical patient monitor and ventilator alarms in the context of a private room neonatal intensive care setting.MethodsThe study design comprised of both a questionnaire and video monitoring of nurse-responsiveness to critical alarms. The Likert scale questionnaire, comprising of 50 questions across thematic clusters (critical alarms, yellow alarms, perception, design, nursing action, and context) was administered to 56 nurses (90% response rate). Nearly 6000 critical alarms were recorded from 10 infants in approximately 2400 hours of video monitoring. Logistic regression was used to identify patient and alarm-level factors that modulate nurse-responsiveness to critical alarms, with a response being defined as a nurse entering the patient’s room within the 90s of the alarm being generated.ResultsBased on the questionnaire, the majority of nurses found critical alarms to be clinically relevant even though the alarms did not always mandate clinical action. Based on video observations, for a median of 34% (IQR, 20–52) of critical alarms, the nurse was already present in the room. For the remaining alarms, the response rate within 90s was 26%. The median response time was 55s (IQR, 37-70s). Desaturation alarms were the most prevalent and accounted for more than 50% of all alarms. The odds of responding to bradycardia alarms, compared to desaturation alarms, were 1.47 (95% CI = 1.21–1.78; <0.001) while that of responding to a ventilator alarm was lower at 0.35 (95% CI = 0.27–0.46; p <0.001). For every 20s increase in the duration of an alarm, the odds of responding to the alarm (within 90s) increased to 1.15 (95% CI = 1.1–1.2; p <0.001). The random effect per infant improved the fit of the model to the data with the response times being slower for infants suffering from chronic illnesses while being faster for infants who were clinically unstable.DiscussionEven though nurses respond to only a fraction of all critical alarms, they consider the vast majority of critical and yellow alarms as useful and relevant. When notified of a critical alarm, they seek waveform information and employ heuristics in determining whether or not to respond to the alarm.ConclusionAmongst other factors, the category and duration of critical alarms along with the clinical status of the patient determine nurse-responsiveness to alarms.

Does the architectural layout of a NICU affect alarm pressure? A comparative clinical audit of a single-family room and an open bay area NICU using a retrospective study design

“…34–36 In particular, the ECRI Institute highlights that collecting and analysing ventilator data can be challenging, and limited research exists on ventilator alarms. 19 24 37 To the best of our knowledge, this study is the largest audit of ventilator alarms, and we show that the daily alarm pressure (average) because of ventilators, in fact, exceeds that due to patient monitors alone. It should be noted that although on average ventilator alarm pressure is high, it is also dependent on the mode of ventilation.…”

“…In a previous study carried out in the SFR NICU of MMC, we identified that the median nurse response times to red desaturation alarms was quite long at 56 s. 19 Since extended desaturation events are associated with adverse outcomes, there is a natural tendency for SFR NICUs to err on the side of caution and opt for shorter delays. 27 However, for the OBA NICUs with direct visual oversight and potentially shorter distances and nurse response times, slightly longer delays in generating the alarm, on average, help in reducing the mean daily duration for which the alarms sound and reduce noise in the typically noisier OBA environment.…”

“…While on the one hand, infants in the SFR NICUs may have reduced exposure to noise which enhances physiological stability and reduces alarms; on the other hand, long nurse response times to alarms may, in fact, result in an increased number of alarms. 19 20 Furthermore, reduced patient visibility can also change nursing workflow with implications for the physiological stability of infants, nurse handling of alarms and perceived alarm pressure.…”

A Ballistographic Approach for Continuous and Non-Obtrusive Monitoring of Movement in Neonates

“…The fact that motor response often precedes changes in vital signs can be exploited for the early generation of alarms – an important issue in the NICU – potentially increasing the window of opportunity for nurses to respond to critical alarms [39] , [40] . Literature also shows that spontaneous movement can lead to various physiological perturbations, including increased oxygen consumption due to metabolic demands, movement-induced hyperventilation, and hypocapnia.…”

Critical care nurses’ knowledge of alarm fatigue and practices towards alarms: A multicentre study

“…Researchers have only recently been exploring the phenomenon of alarm fatigue (Alsaad et al, 2017;Bonafide et al, 2014;Cho et al, 2016;Deb and Claudio, 2015;Drew et al, 2014;Funk et al, 2016;Gazarian et al, 2015;Honan et al, 2015;Joshi et al, 2017;Varpio et al, 2012), and most of this research emanates from North America. This could in part be explained by the different nurse-patient ratios between the US and elsewhere and the practice of nursing patients in single rooms rendering American nurses more reliant on alarms to monitor their patients.…”