CLINICAL ALARM HAZARDS were the number one health technology hazard from 2010 to 2014.1 Between January 2005 and June 2010, 566 alarm-related deaths were reported in a Food and Drug Administration database.2 Similarly, between January 2009 and June 2012, 80 alarm-related deaths were reported in The Joint Commission (TJC) sentinel event database.2 Those deaths were attributed to delays in care because of alarm fatigue. Alarm fatigue can be defined as desensitization to alarms related to the high volume of false or nonactionable alarms or apathy to alarms as a result of the overuse of continuous cardiac monitoring (CCM).3 In a study by Korniewicz et al4 using the Healthcare Technology Foundation Clinical Alarm Survey (HTF CAS), 81% of 1300 health care professionals believed nuisance alarms occurred frequently, 77% believed these disrupted patient care, and 78% believed this reduced trust in the alarms.
In January 2010, a patient awaiting pacemaker placement experienced bradycardia and asystole, which led to the patient's death. In a newspaper article, Kowalczyk5 reported that despite the patient being on CCM, "10 nurses on duty that morning could not recall hearing the beeps at the central nurses." The Centers for Medicare & Medicaid Services stated that desensitization to cardiac monitor alarms played a role in this patient's death.5 This desensitization, a component of alarm fatigue, has impacted patient safety and has resulted in patient deaths across the country. In 2013, TJC responded to the concerns about alarm fatigue and proposed a 2014 National Patient Safety Goal on alarm management to reduce alarm fatigue.6
ALARM FATIGUE AND IMPACT ON PATIENT SAFETY
Alarm fatigue is composed of 2 components. The first is alarm desensitization that stems from excessive alarms causing the nursing staff to tune out the alarm or silence it. Korniewicz et al4 estimated that individual patients might have several hundred alarms per day, resulting in thousands of alarms per unit and tens of thousands of alarms hospital-wide. This overwhelming number of alarms can cause staff to become desensitized to alarm signals and alarms may be disabled, silenced, or ignored.7 Sendelbach and Jepsen8 found that although humans have difficulty discerning more than 6 alarm tones, the number of alarms in acute care areas has dramatically increased.
A second component to alarm fatigue is alarm apathy. Patient monitor systems have a high sensitivity to capture all possible clinical events. This can cause many false positives and nonactionable alarms to occur. As a result, the registered nurse (RN) may lose trust in the system and devalue the alarms. This apathy can result in failure to recognize an acute change in patient condition. It is well established that many false-positive and nonactionable alarms occur with CCM. In 2012, Welch found that users of CCM reported more than 350 alarms per patient per day, and of these, only 5% needed clinical intervention.9 The other 95% represented nuisance alarms, or alarms that do not require clinical intervention.
Alarm apathy may also occur with overuse or prolonged use of CCM. When patients are kept on CCM when not needed, nurses can begin to devalue monitoring overall. In 2004, the American Heart Association (AHA) and American College of Cardiology (ACC) published Practice Standards for Electrocardiograph Monitoring in Hospital Settings.10 Per these guidelines, CCM is intended for patients who are at high risk for developing clinically significant cardiac arrhythmias. Despite these guidelines, CCM is often applied inappropriately to a large number of patients, and once applied, patients often continue to be monitored for their entire hospital stay without a clinical indication. One study found that out of 1816 patients in cardiac units, 85% had no indication for CCM when using the AHA/ACC guidelines.11
At a large Midwestern teaching hospital in an urban setting, an increasing number of CCM-related delays in care were attributed to alarm fatigue. The hospital CCM system used to monitor technicians who individually monitor up to 60 cardiac monitors on 9 medical/surgical units and 4 progressive cardiac floors. Each monitor technician can triage up to 2604 alerts per hour.
The purpose of this project was to investigate the impact of an evidence-based alarm management strategy on patient safety and alarm fatigue. This strategy integrated the recommendations from the American Association of Critical Care Nurses (AACN),12 including (1) daily electrode replacement with proper skin preparation, (2) elimination of nonactionable and duplicate alarms and adjustment of default threshold alarms, (3) education and guidelines for the RN and monitor technician staff to customize alarms, and (4) reducing CCM overuse by implementing AHA/ACC guidelines. The short-term outcomes were to decrease the total number of alarms and prolonged unnecessary use of CCM through nursing and monitor technician education. The long-term outcomes were to decrease perception of alarm fatigue and eliminate sentinel events.
This AACN alarm management strategy was implemented at a 580-bed not-for-profit, Magnet-recognized hospital that is part of a large 11 hospital health care systems. The quality improvement project was approved by the institutional review board.
For this project, the Plan-Do-Check-Act model was used to guide the improvement process.
To steer this work, a Cardiac Monitor Committee (CMC) was established. It consisted of key stakeholders who were identified on the basis of their role in the hospital, including the cardiology clinical nurse specialist, nurse manager of CCM, nurse manager of the medical/surgical unit, several RNs from the progressive and medical surgical units, nursing director of cardiology, cardiology nurse educator, a hospitalist, a cardiologist, and monitor technicians. Members were given information about the AACN's alarm management strategy. Key interventions were decided on by the CMC members and prioritized.
All 5 of the AACN alarm strategy interventions were piloted on 1 to 2 units. Each intervention pilot included obtaining baseline alarm data, providing education to the RN and monitor technician staff about the intervention, identifying champions, and obtaining postintervention data. The pilots also determined barriers to overall implementation of the alarm management strategy.
Daily electrode change
First, the CMC approved a daily electrode change to be completed at 10 AM, assuming that electrodes would be changed with daily morning care. Baseline data were obtained and education was created for the nursing staff on the daily electrode change. Postintervention data were obtained 2 weeks after the intervention was started, and a 33% reduction in alarms was observed. In addition, a decrease of 26% in artifact alarms occurred.
Elimination of nonactionable and duplicate alarms and adjustment of thresholds
Next, the CMC decided on changes to the default alarm changes. Baseline alarm data were obtained from 2 units. The data were analyzed by alarm type to determine which alarms were triggering most frequently. Next, the CMC determined which alarms were not actionable for this hospital's specific patient populations. Education was created for the nursing staff, monitor technicians, and health care providers on the 2 pilot units. The education included not only the alarms that were being turned off, but also alarms that were still left turned on. This was important as it allowed the nursing staff to know that alarms were still in place for their patients. After the education was completed, alarm changes were made to the central monitoring stations for the pilot units. These settings became the default settings for all patients admitted but could be customized by the nurses for each patient as needed.
This intervention showed promising results. The elimination of nonactionable and duplicate alarms and adjustment of default threshold alarms resulted in a 36% reduction on 1 unit and an 84% reduction on the second unit. The unit with the lesser reduction had 1 patient who accounted for the majority of the alarms.
The CMC proceeded with alarm customization. For this pilot, a cardiac progressive care unit and medical unit were identified, and baseline alarm data were obtained. It was decided to use the cardiac monitor system technology that would allow for auto-customization of these alarms. Education was provided to the RNs and monitor technicians. Unfortunately, after implementation, there was a considerable increase in the alarms-up to 300%-because the alarms were not adjusted quickly enough as the patient's heart rate or pulse oximetry moved from baseline. The setting was turned off after 2 days because of the increase in alarms: this alarm management strategy was not implemented in the hospital-wide implementation.
Appropriate use of telemetry
Lastly, the CMC focused on telemetry utilization. For this intervention, the CMC opted to ensure that patients who no longer required monitoring were taken off in a timely manner. Patients in medical/surgical nursing units who were arrhythmia-free for 48 hours were evaluated on a daily basis for possible removal of CCM. The monitor technicians identified the patients and notified the RNs who in turn contacted the health care provider. Nursing staff, monitor technicians, and health care providers were educated on this process and on the AHA/ACC guidelines. The pilot resulted in an average of 15 patients identified per day with the potential to remove CCM with the actual removal of 6 patients per day.
Each unit-based intervention pilot was evaluated not only to determine the overall decrease in alarms but also to identify what changes needed to be made before a hospital-wide implementation. Barriers were identified and changes to education were made. Standard work documents were created to ensure that expectations were clear.
The CMC evaluated the daily electrode pilot and moved the standard monitor electrode change time to the evening shift. In addition, skin concerns led to a change in the type of electrode used. All alarms were reviewed, and a complete list was identified to turn off for the full hospital implementation.
Although the use of technology to help with alarm customization was not successful, more education was provided to the nursing staff about alarm customization. The RN was ultimately responsible for the correct alarm settings, and it was within the scope of the RN to customize the alarms.
Lastly, it was determined that more education was needed for health care providers to feel comfortable taking patients off cardiac monitoring after 48 hours when called by the RN. Champions were identified within the hospitalist and resident groups to educate providers about the guidelines and risks of leaving patients on cardiac monitoring too long. Data were announced daily at the hospital-wide daily safety check-in.
With the pilot completed, the interventions were implemented on all adult noncritical care units. The implementation plan included tools to assist with hospital-wide implementation-a SharePoint site on the hospital intranet, manager tools with Situation-Background-Assessment-Recommendation and Frequently Asked Questions flyers, standard work documents, pilot data, and narrated PowerPoint to reinforce live inservice education.
The intervention of the daily electrode change with proper skin preparation resulted in an 18.5% reduction in overall alarms. Further evaluation showed significant reduction in individual alarms as shown in the Figure.
|Figure. Daily electrode change with percent reduction. HR, heart rate; PVC, premature ventricular contraction; RR, respiratory rate; SVT, supraventricular tachycardia; V-fib/Tach, ventricular fibrillation/tachycardia; VT, ventricular tachycardia.|
Default alarm settings were changed throughout the hospital in collaboration with the manufacturer of the patient monitoring system. This intervention showed an overall 30% reduction in alarms. Further investigation of the data showed that, as with the pilot, there were a few patients who caused the majority of the alarms.
During the first week, an average of 16 patients were identified daily for possible discharge from CCM. Of these, an average of 7 patients were actually discharged. The hospital averages a daily census of 190 patients on CCM. The daily evaluation of patients represents a reduction of 3.5% in census. On the basis of literature that showed the cost of CCM and nursing time,13 this has the potential to save $136 500 per year and 841 hours of RN time per year.
Perception of alarm fatigue
The HTF CAS was used to evaluate the perception of alarm fatigue among nursing staff and the monitor technicians. This tool consists of 21 questions on a 5-point Likert scale that ranges from 1 (strongly disagree) to 5 (strongly agree). This tool does not generate an overall score to measure alarm fatigue; rather, it gives insight into the staff's perception on how the alarms are affecting patient care. Nursing staff and monitor technicians on 1 nursing unit completed this survey before and after implementation of the alarm management strategy. The preintervention survey had 79 staff respondents (59% RNs, 41% monitor technicians). The postintervention survey had 47 staff respondents (57% RNs, 43% monitor technicians). After implementation of the alarm management strategy, 12% fewer staff believed that nuisance alarms occurred frequently. In addition, 11% fewer staff believed there were missed alarms. Finally, staff continued to believe that nuisance alarms disrupted patient care. During the time of the implementation of the alarm management strategy, staff engaged in frequent conversations about patient monitoring, and leadership emphasized its importance. The HTF CAS results supported this heightened awareness. The results showed a 3% increase in the number of staff respondents who agreed and strongly agreed that staff respond quickly to alarms. In addition, there was an 8% increase in the number of respondents who felt nuisance alarms could reduce trust in alarms that occurred and another 8% more staff (17%) were aware of the alarm management policies after the intervention; 14% more staff reported the TJC National Patient Safety Goal reduced alarm adverse events; and 21% more staff reported the alarms for their unit were appropriate to alert for changes in the patient's condition (Supplemental Digital Content, Figure available at: http://links.lww.com/JNCQ/A288).
During this 2-year project, there were no sentinel events identified with CCM. The Risk Manager on the CMC monitored the electronic incident reporting system for any report that might be associated with this monitoring.
The use of an evidence-based alarm management strategy was shown to be an effective method to decrease alarms, decrease unnecessary prolonged use of CCM, decrease the perception of alarm fatigue, and improve patient safety. A recent article by Sendelbach et al14 supported the concept that an effective alarm management strategy would influence patient safety by ensuring alarms are correct and actionable. In that article, the authors implemented similar strategies on the basis of the AACN Alarm Management Strategy guidelines to reduce alarms. They found that the bundled interventions had an 80% to 90% reduction in alarms on pilot units.
Through the implementation, changing of the default alarm settings had the largest impact on alarms and was the easiest to implement. During the planning, this took time for the CMC to evaluate the alarm settings before making the change; however, once the change was made, it was immediately implemented in the patient monitoring system. These settings were embedded into the default settings to ensure high reliability of the appropriateness of the alarms. In addition, these settings have become the standard alarm settings for all adult patients on CCM throughout this hospital system.
The intervention of the daily electrode change and proper skin preparation was more challenging to implement. This required a change in behavior and culture regarding electrodes. It needed constant reinforcement. Skin issues arose from daily electrode changes and improper removal of the electrodes. Clinical nursing staff collaborated with the manufacturer of the electrodes to determine which electrodes were best for specific patient populations and were easiest on the skin. Clinical educators provided education on the appropriate application and removal of the electrodes. These interventions decreased the reported skin issues.
Implementing the alarm management strategy guidelines also seemed to decrease the perception of alarm fatigue on the units as shown with the HTF CAS. The staff had a heightened awareness of the issue of alarm fatigue, the TJC National Patient Safety Goal, and polices that were in place to address alarm settings. Leadership prioritized alarm management and frequently engaged in conversations with staff about the impact of alarm fatigue on patient safety.
There were several limitations identified with this initiative. First, data collection was a challenging process. The large spreadsheets were challenging to manipulate. The interventions were rolled out separately to evaluate the impact of each individually; however, there was not a sense of the overall impact of all of the interventions on the alarm numbers. During this project, changes in team members also presented challenges. Alarm customization was an important aspect to alarm management. The inability to use technology to assist with this was disappointing and unexpected. Finally, the complexity of patient monitoring at this organization was challenging. As is likely the case with many organizations, the patient monitoring system is one that evolved over time. There were processes or barriers that did not support the changes that were being implemented, including monitor technician workload, communication between the RN and monitor technician, and appropriate notification of alarms. These had to be addressed for the alarm management work to continue.
Implications for nursing practice
This quality improvement initiative has many implications for nursing practice. First is the need for enhanced methods to customize alarms. Future projects should focus on methods that can help provide guidance to the nursing staff on alarm customization. In a systematic review of the literature, Konkani et al15 found that the having a culture of customizing alarms for individual patients is the best method to decrease alarms. One strategy that will be implemented in the future at this organization will be to use the monitor technician as the expert who makes recommendations on the alarm customization to the RN. The RN would have the responsibility to ensure that customization is appropriate for the patient. Furthermore, the design of smart alarms for practical use should be continued. Konkani et al15 described these smart alarms systems having the ability to pull information from multiple devices to ensure accuracy of the alarms. This would help to ensure the validity of the alarm and to customize it on the basis of the patient's need.
Another implication is the need for continual evaluation of appropriate default alarm settings at individual organizations. This is not a "once and done" type of project. There are always opportunities to continue to adjust the default alarm settings. In this project, once initial alarms were turned off and postdata were collected, it became clear that other alarms should be evaluated to determine their clinical significance.
There is a need for organizations to focus on standardization of their default alarm settings. Organizations should look alarm settings across a population, such as adult, pediatrics, and neonates, rather than a unit-by-unit basis. This allows for synergy among the multiple areas within the organization as well as improved, standardized patient care. In a time where resources in hospitals are limited, focusing on alarm standardization from an organizational level will improve efficiencies.
Lastly, continued work needs to be done to ensure that only patients with the need for CCM are being on continuously monitored. There is a perception that patients on CCM are being watched closer even though the literature suggests otherwise.11,16 Appropriate-use criteria need to be embedded into hospital policy and actualized in computerized physician order sets. Nurse protocols should be developed that allow for the removal of CCM in patients who no longer meet criteria. Appropriate use of CCM needs to have the same attention that health care has focused on tests and procedures.
Organizations need to continue to address patient monitoring alarms. The validity of the alarms must be ensured so that staff can reliably respond to them. This pertains not only to patient monitoring but also to any device that has alarm signals. Nursing should no longer accept "out of the box" alarm settings; all alarms should be evaluated and changes made on the basis of the population's needs. The use of an evidence-based alarm management strategy can reduce alarm fatigue and ensure the safety of all monitored patients.