Alarm Fatigue in the ICU. Lynn Maguire MS, RN, PMC, NE-BC

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1 Alarm Fatigue in the ICU Lynn Maguire MS, RN, PMC, NE-BC

2 Objectives At the completion of this lecture the participant will: Define Alarm Fatigue Discuss the Joint Commission s Patient Safety Goal regarding Alarm Fatigue Identify the most common sources of Alarm Fatigue Identify a minimum of 3 contributing factors to Alarm Fatigue Identify 3 strategies to reduce nuisance alarms in the ICU

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4 Definition Alarm Fatigue Occurs when staff members are exposed to an excessive number of alarms. Staff become desensitized to alarms. Results in sensory overload: Staff frustration Delayed alarm response Missed alarms Patient safety events

5 Alarm Sources

6 Contributing Factors

7 Unintended Consequences Since 2005, more than 216 patient deaths have been directly attributed to alarm fatigue. 77-year old was admitted to a telemetry unit. Alarms for low battery went unanswered. Patient had cardiac arrest and died.

8 Unintended Consequences January year-old patient was in the ICU. Bedside alarm was turned off. Alarm sounded at the central nurses station. Nurses on duty said they did not hear the alarm or see the digital display.

9 Unintended Consequences Patient Death August year-old man was admitted to the ICU after a tree fell on him, resulting in facial trauma and head injury. He was agitated and received lorazepam 5 mg IV push. The order was for small doses up to 5 mg. An hour later, tachycardia and low oxygen saturation (SpO 2 ) alarms went unanswered for an hour. Respiratory arrest was called. Patient was resuscitated and placed on a ventilator. CT scan showed an anoxic injury of the brain. Family withdrew the patient from life support after several days.

10 Statistics

11 Impact/significance Studies show it is difficult for humans to differentiate among more than 6 different alarm sounds The average number of alarms in an ICU has increased from 6 in 1983 to more than 40 different alarms in % to 99% of electrocardiographic (ECG) monitor alarms are false or clinically insignificant.

12 Research Results University of Utah observational study results 200 observational hours in an ICU 1,214 alarms 6.07/hour 145/patient day 5.7% were actionable patient-related alarms 17.7% were actionable technical alarms An alarm delay of 19 seconds would reduce alarm occurrence by 67%

13 Alarm Classifications False alarms (causes) Patient motion Poor sensor placement Intermittent cables Limitations in the device alarm detection algorithm Non-actionable alarms. True alarms that require no intervention and usually correct themselves Low O 2 Saturation Heart rate Suctioning Actionable alarms Need immediate action Life threatening

14 Joint Commission National Patient Safety Goal Background NPSGs were established in 2002 Patient Safety Advisory Group advises Joint Commission on the development & updating of NPSGs NPSGs developed in response to: Sentinel Events Survey findings Changes in standards

15 Joint Commission National Patient Safety Goal Clinical Alarm Safety Goal 6 Reduce the harm associated with clinical alarm systems Use alarms safely NPSG Make improvements to ensure that alarms on medical equipment are heard and responded to on time.

16 JCAHO Sentinel Events Report January 2009-June Events reported to JCAHO involving alarms 80 resulted in patient deaths 13 resulted in permanent loss of function 5 resulted in unexpected additional care or extended stay Injuries/deaths/delays due to: Falls Delays in treatment Ventilator use Medication errors

17 JCAHO Sentinel Events Findings Alarm signals inappropriately turned off. Absent or inadequate alarm system. Alarm signals not audible in all areas. Improper alarm settings.

18 JCAHO Additional contributing factors included: Alarm fatigue. Alarm settings not customized to the individual patient or patient population. Inadequate staff training. Inadequate staffing to support or respond to alarms. Alarm conditions and settings not integrated with other medical devices. Equipment malfunctions and failures.

19 JCAHO Strategies Develop a multidisciplinary team to review trends and develop protocols. Ensure that there is a process for safe alarm management and response. Establish guidelines for alarm settings, including individualizing alarm settings and limits, when limits can be modified, and to what extent. Take appropriate measures to reduce the number of nuisance (false positive) alarms. Identify when alarm signals are not clinically necessary. Clarify who is responsible for alarm notification and response.

20 JCAHO Strategies con t Assess the acoustics in the patient care area and modify as needed to ensure that critical alarms can be heard. Develop clear protocols for handoff communication Routinely inspect and maintain alarm-equipped devices. Carefully analyze potential alarm-related problems. Adequately train staff. Build a culture of safety.

21 Expected Practice and Nursing Actions Provide proper skin preparation for ECG electrodes Wash the isolated electrode area with soap and water, wipe the electrode area with a rough washcloth or gauze, and/or use the sandpaper on the electrode to roughen a small area of the skin Do not use alcohol for skin preparation; it can dry out the skin

22 Expected Practice and Nursing Actions Customize alarm parameters and levels on ECG monitors Customize the alarms to meet the needs of individual patients Set customized alarms within 1 hour of assuming care of a patient and as the patient s condition changes Change ECG electrodes daily. Change daily or more often if needed

23 Expected Practice and Nursing Actions Customize delay and threshold settings on oxygen saturation via pulse oximetry (SpO2) monitors. Collaborate with an interprofessional team, including biomedical engineering, to determine the best delay and threshold settings Use disposable, adhesive pulse oximetry sensors, and replace the sensors when they no longer adhere properly to the patient s skin.

24 Expected Practice and Nursing Actions Provide initial and ongoing education about devices with alarms Provide education on monitoring systems and alarms, as well as operational effectiveness, to new nurses and all other health care staff on a periodic basis Budget for ongoing education when purchasing monitoring systems.

25 Expected Practice and Nursing Actions Establish interprofessional teams to address issues related to alarms, such as the development of policies and procedures Determine the default alarms for the equipment being used Evaluate the need to upgrade to next-generation pulse oximetry Consider developing a culture of suspending alarms when nurses perform patient care that may produce false alarms DO NOT TURN ALARMS OFF! Standardize monitoring practices across clinical environments

26 Expected Practice and Nursing Actions Monitor only those patients with clinical indications for monitoring Collaborate with an interprofessional team to determine those patients in a population or care unit who should be monitored and what parameters to use Use the American Heart Association s Practice Standards for ECG Monitoring in Hospital Settings: Executive Summary and Guide for Implementation

27 SpO 2 Alarm Suggestions Single-patient use sensors for continuous monitoring Proper placement of SpO 2 sensor Cable maintenance and routine replacement Decrease alarm thresholds from 90% to 88% Set a 15 second alarm delay

28 Alarm Optimization

29 Toolbox of Alarm Management Resources AACN Practice Alert ( The Joint Commission proposal: 2014 National Patient Safety Goal on Alarm Management ECRI Institute ( Healthcare Technology Foundation ( U.S. Food and Drug Administration Medical Devices ( Advancing Safety in Medical Technology Healthcare Technology Safety Institute ( Industry partners Physiologic monitoring system manufacturers Ventilator manufacturers Infusion pump manufacturers Pulse oximetry device manufacturers Bed manufacturers Wired and wireless communication systems manufacturers

30 References Welch, J. (2011, Spring). An evidence-based approach to reduce nuisance alarms and alarm fatigue. Horizons, Ulrich, Beth; Nephrology Nursing Journal, 2013 Jul-Aug; 40 (4):

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