Alarm Fatigue in the Intensive Care Unit: A Performance ...



Alarm Fatigue in the Intensive Care Unit: A Performance Improvement ProjectMichele JonesState University of New York Polytechnic InstituteAlarm Fatigue in the Intensive Care Unit: A Performance Improvement ProjectIntroductionThe topic I have chosen for my scholarly paper is monitor alarm fatigue in the intensive care unit (ICU). Alarm fatigue does not have a single clear definition but one accurate definition “is the desensitization of a clinician to an alarm stimulus that results from sensory overload causing the response of an alarm to be delayed or missed” (West, Abbott, & Probst, 2014, para. 2). Nuisance alarms are those that activate but are not clinically significant (Welch, 2011). In the ICU that was reviewed the different types of alarms included patient call bells, bathroom alarms, personal alarms, code blue alarms, staff assist alarms, monitor alarms, balloon pumps, dialysis machines, IV pumps, tube feeding pumps, and ventilator alarms. This topic is of interest to me because as an ICU nurse I am surrounded by frequent audible alarms, as are my co-workers and our patients. My investigation occurred at Bassett Medical Center and my mentor is Lee Talaia RN BSN CCRN. This issue is of importance to this unit and facility because in high acuity units such as this one alarm fatigue can lead to alarms being disabled to avoid the frequent audible alarms ("Serious Issue," 2014). Disabling alarms can result in a delayed response to changes in a patient’s condition. Excessive alarming can cause stress on patients as well as staff.PICO QuestionIn intensive care units (P), how does adjusting monitor alarms at the beginning of each shift so that they are patient specific, changing disposable equipment at regular intervals, educating staff, and creating a delay between alarm and audible alarm (I) compare to our current practice which is recommended but not enforced or regulated (C) reduce nuisance alarms and alarm fatigue?Nuisance Alarms, Alarm Fatigue and the ICUNuisance Alarms and Alarm Fatigue are an ICU IssueNuisance alarms can result in alarm fatigue which can have a negative impact on patient outcomes and patient safety. Nuisance alarms increase the number of distractions facing nurses and other clinical staff. These distractions can prevent nursing staff from concentrating on patient care interventions which can lead to errors and suboptimal patient care (West et al., 2014). This is a current issue for the ICU and according to the ECRI Institute, this issue has been on the top 10 list of patient safety issues for the past seven years (Small, 2015; Welch, 2011). There were 80 fatalities and 98 sentinel events that resulted from alarm issues from 2009-2012 (West et al., 2014).Changing Practice in the ICUInvestigating this issue can change practice in the ICU. Implementing strategies identified in this scholarly activity can reduce nuisance alarms and alarm fatigue. It can also reduce distractions for clinical staff and decrease the number of interruptions to patients’ sleep periods. Most of the interventions identified in this research are easily and quickly implemented and have been shown to effectively reduce nuisance alarms.Florence Nightingale’s Environmental TheoryFlorence Nightingale is recognized for her environmental theory. This theory states that a patient’s environment impacts their recovery. It stresses the importance of a quiet environment to promote healing and gives the nurse the responsibility of creating the proper environment for recovery ("Environmental theory," 2013)Unnecessary noise causes interruptions of sleep and rest for patients. These interruptions can lead to patient confusion which sometimes requires additional interventions such as restraints and prolonged hospital stay. Excessive noise can cause anxiety for patients and it can have a negative impact on how patients perceive the clinical abilities of the staff. Intubated and sedated patients can hear the noises that surround them and as Nightingale theorized, ill patients are more sensitive to their environment (Mazer, 2012). “Patients exposed to continuous extraneous noise can also experience altered memory, increased agitation, less tolerance for pain, and … these environmentally generated symptoms are often medicated” (Mazer, 2012, p. 352). This statement reinforces the importance of reducing excessive noise to improve the quality of care given to patients. High noise levels also have a negative impact on staff. Continuous noises can lead to nurse burn-out as well as distractions that can result in nursing errors (Mazer, 2012) and nurses can have physical symptoms such as headaches (Cvach, 2012).Literature ReviewThe Causes of Nuisance AlarmsNuisance alarms are likely to occur when protocols do not exist or if they are not enforced. These protocols give guidance abut proper response to alarms and setting alarm parameters that are patient specific (McKinney, 2014). Nuisance alarms also result from lack of education about the devices being used and how to effectively troubleshoot alarms (Cvach, 2012). Another cause of nuisance alarms is not using technology to its maximum potential or using technological devices that need repair (Welch, 2011). The causes of nuisance alarms are multifactorial and therefore an approach to reduce nuisance alarms should also be multidisciplinary. A task force dedicated to reducing nuisance alarms should include nursing staff, physicians, biomedicine, and support staff who assist with observing the monitors or connecting patients to the monitoring devices.How to Reduce Nuisance Alarms and Alarm Fatigue TC "Bedside implementations" \l "3" Bedside implementations. There are many simple interventions that can be implemented by nurses to reduce nuisance alarms and alarm fatigue. These include suspending alarms when performing care that results in unnecessary alarming such as repositioning a patient (Cvach, 2012). Other interventions include proper device setup and regular replacement (Garland, 2015). Also, nurses should adjust alarm parameters so that they are specific for each patient (Welch, 2011).Nuisance alarms commonly occur when repositioning or suctioning a patient. Suspending the alarms on the ventilator and the cardiac monitor during these interventions will reduce the occurrence of these alarms (Cvach, 2012). It can be appropriate to suspend alarms during these times because the nurse is at the bedside and is able to observe changes on the monitor, the ventilator and the patient. It is not necessary to have an audible alarm if the nurse is aware that the audible alarm is disabled for that short period of time.Evidence based research identifies several steps to improve EKG electrode conduction to reduce artifact and nuisance alarms. It is recommended that the patient’s skin be cleansed and dried with a rough towel to remove any loose fragments of skin that may impede conduction. Also, if the area has a large amount of hair it is recommended to shave the locations where electrodes will be placed. Replacing electrodes every 24 hours can have a significant impact on reducing nuisance alarms ("Alarm management," 2013).One way to promote the customization of alarm parameters is to develop education to review the basics of proper alarm management and how to troubleshoot alarms. It is important to test the nurses’ knowledge of the monitors and appropriate parameters, prior to offering education. This will help to ensure that the existing knowledge gaps are addressed (Graham & Cvach, 2010). After the initial education it is important to reinforce the information with continued education ("Alarm management," 2013). This knowledge can assist nurses in implementing the recommended practice guidelines with respect to alarm parameters. It can also give nurses more autonomy and increase their comfort level with the monitoring devices. Nurses can use the knowledge they gain in addition to their critical thinking skills to customize alarm parameters for each patient and this can help reduce nuisance alarms. TC "Biomedical interventions." \l "3" Biomedical interventions. Another way to reduce nuisance alarms is to ensure that the equipment that is being used is appropriate and that it is being used to its maximum potential. Smart technology considers trending of data instead of a single snapshot of information which can decrease clinically insignificant alarms (Cvach, 2012). There are also options of delaying audible alarms which can be useful when applied to alarms that last for short time periods and do not require intervention (Welch, 2011).Clinical staff and biomedicine have to communicate and work together to ensure that the proper equipment is chosen and that it is being used appropriately. Smart technology uses algorithms and trending to filter nuisance alarms. Frequently, an audible alarm will silence itself due to the short duration of the alarm (Cvach, 2012). This can lead to nurses ignoring audible alarms because they are accustomed to the alarms auto-silencing (McKinney, 2014). If the short duration of the alarm is the reason that clinical intervention is not required, then it may be possible to implement an alarm delay. The visual alarm on the monitor screen would still activate but there would be a specified time delay before the audible alarm activated. This could reduce alarms that reflect conditions that are so short-lived that they do not require intervention (Cvach, 2012). TC "Educating staff members." \l "3" Educating staff members. It is imperative to identify the current knowledge in a unit prior to developing educational programs. After the knowledge gaps are identified effective education can be developed. In an effort to reduce excessive alarms nurses need to have the knowledge to troubleshoot alarms. They also need guidance regarding setting appropriate alarm parameters that are specific for each patient (Cvach, 2012). In addition, nurses and support staff should be knowledgeable about proper device set-up and maintenance as well as how the devices obtain and display information (Garland, 2015).It is important to educate staff regarding the different types of alarms that most commonly activate (Piepenbrink, 2011). If nurses do not understand the physiology behind the alarms then they will not be able to effectively customize alarm parameters. One way to educate nursing about how to customize alarm parameters is to develop a portable monitor to demonstrate this intervention. This allows nurses to see the device and have a hands on learning experience as well as eliminates the challenges associated with teaching a large number of people within a classroom (Piepenbrink, 2011). TC "Implementing effective policies and procedures." \l "3" Implementing effective policies and procedures. Policies and procedures provide guidance for staff regarding implementing the above interventions as well as give the staff the resources to improve autonomy with these interventions. The Joint Commission recognizes the importance of protocols that attempt to reduce nuisance alarms and they are mandating that hospitals have the protocols in place by the year 2016 (McKinney, 2014).ResultsIt was determined that several knowledge deficits were identified among staff. These included when to replace disposable monitoring equipment, how to troubleshoot device alarms, and when to re-evaluate and adjust alarms during a shift. The intensive care unit reviewed does not have a protocol regarding reducing nuisance alarms and alarm fatigue. It was noted that nursing staff was unaware of the implications of nuisance alarms and alarm fatigue.Data was obtained from the physiologic monitors within the unit and it was found that over a 36 hour timeframe there were 594 audible alarms and 30 of those were clinically significant. The most frequent clinically insignificant alarm was PVCs/minute high which tallied 327 of the 594 total alarms. Irregular rhythm alarms accounted for 69 of the alarms and the patients’ nurses confirmed that none of the alarms were clinically significant. Premature ventricular response (PVC) pairs, non-sustained ventricular tachycardia (NSVT) and multi-focal PVCs were the next most frequent clinically insignificant alarms and accounted for 51, 30, and 27 alarms respectively.The information gathered from the literature supports the data from the unit reviewed. Some of the interventions mentioned in the literature may be effective if implemented in this unit. As suggested by the literature, a multidisciplinary committee should be established. This committee should gather data over a specified time period and it should include not only physiologic monitor alarms but all other audible alarms within the unit. The committee should thoroughly evaluate the staff’s knowledge regarding monitoring devices and their alarms and the implications of alarm fatigue. Upon gathering this data the committee should implement evidence based interventions and develop a protocol that supports these interventions.Limitations of ResultsThe alarm data that was collected only reflected physiological monitor alarms because there are too many alarming devices within the unit for one person to effectively review. The physiological monitor alarm data was not complete. There are times when patient history is deleted after the patient is monitored by a portable device in the event of ambulation or temporarily transferring out of the unit for testing. Also, there was not available data for patients who had been discharged during the timeframe reviewed. In addition, certain alarms that produce an audible alert do not generate data. These alarms include a poor perfusion of the SPO2 waveform or if a patient has an electrode that is off or not conducting.Performance Improvement ProjectFor this project I gathered data from one type of device that produces an audible alarm, the unit’s physiologic monitors. These devices most often monitor heart rate and rhythm and SPO2. I reviewed all of the alarms and determined which were artifact. I then had discussions with the nurses caring for the patients to determine which alarms required intervention.I also conducted a basic survey to identify areas of knowledge deficit as well as to gain an understanding of general current practice with respect to this issue. An anonymous questionnaire was given that tested nurses’ knowledge about alarm parameters. It also asked the nurses if they customize their patients’ alarm parameters and if they re-evaluate these parameters throughout the shift. The questionnaire asked the nurses if they felt comfortable changing the default alarm parameters. It also asked the nurses if they were confident in troubleshooting physiologic monitor and ventilator alarms.The results obtained in this project were significant and identified that a current national patient safety issue that exists within our own unit. The unit leadership was very supportive of establishing a committee to conduct further research on this issue. The committee will be multidisciplinary and include a mix of experienced and less experienced staff.ImplementationThis facility has begun to form a committee with the purpose of reducing nuisance alarms and monitor alarm fatigue. The committee will be responsible for obtaining thorough data from our audible alarm devices, starting with the physiologic monitors and the ventilators. These two devices were chosen to be addressed first because they were deemed the highest priority due to frequency of alarms and clinical importance of the devices. This data will identify the frequency of alarms and which alarms are clinically insignificant. It will identify strategies to reduce the alarms that are clinically insignificant. The committee will assess the current knowledge and practice of the unit staff with respect to device set-up and maintenance, troubleshooting alarms and the implications of alarm fatigue.The committee will also assist with developing a protocol for reducing nuisance alarms. This protocol will serve as a guideline for both experienced and inexperienced staff. One of the guidelines that are being discussed is that it may be required for nurses to document the alarm parameters that they have set for each patient. This could help hold nurses accountable for their patients’ alarm thresholds and frequency of nuisance alarms. This documentation was previously required when the unit used paper charting. Since the implementation of electronic charting there is not a place to document this information. Another potential part of the protocol could be to replace disposable equipment such as electrodes and SPO2 probes routinely and to perform proper skin preparation when applying the devices.The committee will also be responsible for educating the unit staff about the implications of nuisance alarms and alarm fatigue. Some topic areas that are currently being discussed are the effect on patient rest and recovery, alarm misuse and patient safety, desensitization of staff to alarms, and how nuisance alarms increase the stress level of staff. In the future this committee hopes to be able to use the information they have learned to implement similar strategies in the telemetry units of the hospital. Reducing nuisance alarms in telemetry units can reduce the number of interruptions for nurses which can decrease errors and improve patient safety (Cvach, 2012).The unit will use the data I collected for this project as a starting point for collecting data and assessing current knowledge within the unit. The committee will do a more comprehensive review of the audible alarms in the unit and do a more thorough assessment of staff knowledge. These results will guide interventions and educational efforts.SummaryThis project made me more knowledgeable about the implications of nuisance alarms and alarm fatigue. It also identified areas of weakness within our unit with respect to this issue. Nuisance alarms are one of the top patient safety issues every year and The Joint Commission is taking notice. There will be new requirements forcing hospitals to make efforts to reduce nuisance alarms in an effort to reduce risks to patient safety, promote healing and create a less stressful environment. It is imperative that our unit is proactive in addressing this current issue.ReferencesAlarm fatigue: Serious issue, dire consequences. (2014). AACN Bold Voices, 6(10), 8. Retrieved from management. (2013). CriticalCareNurse, 33(5), 83-86. Retrieved from Cvach, M. (2012). Monitor alarm fatigue: An integrative review. Biomedical Instrumentation & Technology, 268-276. Retrieved from theory: nursing theory. (2013). Retrieved from , B. (2015). Combat alarm fatigue by getting back to basics. CriticalCareNurse, 35(2), 58-9.Graham, K. C., & Cvach, M. (2010). Monitor alarm fatigue: Standardizing use of phyiological monitors and decreasing nuisance alarms. American Journal of Critical Care, 19(1), 28-34. , S. E. (2012). Creating a culture of safety: Reducing hospital noise. Biomedical Instrumentation & Technology, 46(5), 350-355. , M. (2014). Hospital’s simple interventions help reduce alarm fatigue. Modern Healthcare, 44(5), 26-7. Retrieved from , J. (2011). Taking alarm standardization to the floors with a telemetry training system. Biomedical Instrumentation and Technology, 4524-28. , L. (2015). Alarm fatigue, data integrity, patient violence top list of patient safety hazards. Retrieved from , J. (2011). An evidence-based approach to reduce nuisance alarms and alarm fatigue. Horizons, 46-52. , P., Abbott, P., & Probst, P. (2014). Alarm fatigue: A concept analysis. Online Journal of Nursing Informatics, 18. Retrieved from ................
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