The National Association of Clinical Nurse Specialists
Alarm Fatigue
Strategies to Safely Manage Clinical Alarms and
Prevent Alarm Fatigue
NACNS Alarm Fatigue Task Force
Alarm Fatigue Task Force 2013 -2014
JoAnne Phillips (Chair), MSN, RN, CCRN, CCNS, CPPS
Informatics Professional Development Specialist
The University of Pennsylvania Health System
Philadelphia, PA
Joanne.phillips@uphs.upenn.edu
Jacob Ainsworth, MSN, RN, ACNS-BC, NP-C, CCRN-CMC
Cardiology Clinical Nurse Specialist,
Spectrum Health,
Grand Rapids, MI
Jacob.ainsworth@spectrumhealth.org
Rachel Catinella, MSN, RN, CCRN, CNRN (literature table contributor)
Michigan State University CNS Student,
Grand Rapids, MI
Rachel.catinella@spectrumhealth.org
Carolyn Crumley DNP RN ACNS-BC CWOCN
Clinical Nurse Specialist-Adult Health/WOC Nurse
St. Mary's Medical Center
Blue Springs, MO
ccrumley@carondelet.com
Kathleen Ellstrom, PhD, RN, ACNS-BC
Pulmonary Clinical Nurse Specialist,
VA Loma Linda Healthcare System
Loma Linda, CA
Kathleen.ellstrom@va.gov
Rhonda Fleischman, MSN, RN-BC, CNS, CCRN-CMC
Clinical Education Specialist, Cardiac Care Unit,
Aultman Hospital,
Canton, OH
rfleischman@aultman.com
Brenda Moffitt MSN, APRN, CNS-BC
Director, Education and Organizational Development,
Stormont-Vail Health Care
Topeka, Kansas
bmoffitt@stormontvail.org
Patti Radovich, PhD, CNS, FCCM
Nursing Clinical Practice Chair
Manager Nursing Research
Loma Linda University Medical Center, Loma Linda, CA
pradovich@llu.edu
Anita White MSN, RN, ACNS-BC, CCRN
Clinical Nurse Specialist MICU,
Cleveland Clinic,
Cleveland, Ohio
Whitea2@ccf.org
NACNS Alarm Management Toolkit
I.
Introduction and Instructions
Alarm Safety has been named by ECRI the number one technology safety hazard six out of
the last eight years. The number and types of clinical alarms generated by medical devices can
be overwhelming for clinicians, patients and families. “Alarm fatigue,” occurs when clinicians
become desensitized and nonreactive to the sensory overload created by an overwhelming
number of alarms, many of which are nuisance or non-actionable alarms. Delayed response
and silenced alarms constitute significant threats to patient safety. Alarm fatigue has been
implicated as the lead contributing factor in sentinel events related to alarm safety (Sentinel
Event Alert, 2013). In 2014, The Joint Commission established a National Patient Safety Goal to
improve the safety of clinical alarm systems.
Clinical alarms may be associated with physiologic and equipment monitors (e.g., cardiac
monitors and IV pumps) or physical-safety alarms (e.g., bed exit alarms). Clinicians may be
exposed to hundreds of alarms per patient per day. There are complex reasons for the
overwhelming number of alarms, including technology issues, human factors, staffing, and
environment. Appropriate alarm management is a complex, yet essential component of clinical
practice. When alarms are not set or responded to appropriately, clinicians are more likely to
develop alarm fatigue. Patients, families and staff can suffer undue anxiety. Eighty five to
ninety nine percent of alarms do NOT require clinical intervention (Cvach, 2012; Feder & Funk,
2013; Gorges, Markewitz, & Westenskow, 2009; Graham & Cvach, 2010; Sendelbach & Funk,
2013).
It is essential that clinicians mitigate the risks associated with ineffective alarm
management. There are a number of solutions to managing alarms more effectively and safely.
Effective alarm management is influenced by unit culture, infrastructure, nursing practice and
technology. The Clinical Nurse Specialist (CNS) role is uniquely positioned to understand the
variables that facilitate appropriate alarm management and assist staff in implementing
strategies for safe and effective alarm management. The CNS practices within the spheres of
influence of patient/client; nurses and nursing practice; and organizations /system. The CNS will
be able to work collaboratively with an inter-professional team to assess the clinical
environment; and to develop, implement and evaluate appropriate interventions to mitigate
risks associated with ineffective alarm management. These interventions will impact the
patient’s environment, the nurse’s workplace, and the overall clinical environment (Urden &
Stacy, 2011). This toolkit serves as a repository of resources and strategies to effectively and
safely manage alarms and is intended for use by the CNS working to decrease alarm fatigue and
promote safe, effective alarm management in the clinical setting.
References
Cvach, M. (2012). Monitor alarm fatigue: An integrative review. Biomedical Instrumentation &
Technology, 46(4), 268-277.
Feder, S., & Funk, M. (2013). Over-monitoring and alarm fatigue: For whom do the bells toll?
Heart & Lung: The Journal of Acute and Critical Care, 42(6), 395-396.
Görges, M., Markewitz, B. A., & Westenskow, D. R. (2009). Improving alarm performance in the
medical intensive care unit using delays and clinical context. Anesthesia & Analgesia,
108(5), 1546-1552. Doi:10.1213/ane.0b013e31819bdfbb
Graham, K. C., & Cvach, M. (2010). Monitor alarm fatigue: standardizing use of physiological
monitors and decreasing nuisance alarms. American Journal of Critical Care, 19(1), 2834.
Sendelbach, S., & Funk, M. (2013). Alarm fatigue: A patient safety concern. AACN Advanced
Critical Care, 24(4), 378-386. Doi: 10.1097/NCI.0b013e3182a903f9
The Joint Commission, Patient Safety Advisory Group. (2013, April 8). Sentinel Event Alert.
Medical device alarm safety in hospitals. 50. Retrieved from:
http://www.jointcommission.org/sentinel_event.aspx
Urden, L. & Stacy, K. (2011). Clinical nurse specialist orientation: ready, set, go. Clinical Nurse
Specialist, 25(1), 18-27.
Toolkit Contents
This toolkit was developed to help the CNS on their journey to create an alarm safe
environment. The following are the links to the available tools:
1. How to Get Started
a. Describes a Six Sigma process to guide the CNS in a change strategy
i. define, measure, analyze, design, verify
2. NACNS Crosswalk
a. Extensive table of resources from the American Association of Critical Care
Nurses (AACN), the Association for the Advancement of Medical Instrumentation
(AAMI), ECRI, Johns Hopkins, the Joint Commission, and the Healthcare
Technology Foundation.
b. The table contains embedded links, enabling the CNS to have direct access to the
resources.
c. Literature table: an extensive literature review on alarm fatigue is included after
the table, with review and grading of each article.
3. Frequently Asked Questions
a. Series of frequently asked questions from the NACNS list serv and the open
forum at the NACNS National Conference.
NACNS Alarm Fatigue
How do I Start Checklist
Below is an example of a Six Sigma Process approach to change or you may utilize any other change process.
Define: State the problem, specify the customer set, identify the goals, and outline the target process.
Measure: Decide what parameters need to be quantified, work out the best way to measure them, collect the necessary data, and carry out the
measurements by experiment.
Analyze: Identify performance goals and determine how process inputs are likely to affect process outputs.
Design: Work out details, optimize the methods, run simulations if necessary, and plan for design verification.
Verify: Check the design to be sure it was set up according to plan, conduct trials of the processes to make sure that they work, and begin production or
sales.
Plan
Define/Assess
Define:
Alarm safety is the number one technology
hazard in health care. Excessive alarms in
clinical environments lead to alarm fatigue:
staff may ignore or disable a clinically
important alarm.
Assess:
1. Appropriateness of monitoring
a. EB indications for cardiac
monitoring
2. Clinical alarms: current state
a. Unit Gap Analysis (AACN)
b. Alarm data from clinical
engineering / facilities
i. # of alarms / defined
time
ii. # of crisis alarms/
defined time
iii. Current defaults
3. Staff education and competency
a. Current state
Resources
Overview Documents:
NACNS Alarm Fatigue Resource Crosswalk
TJC Goals/Dates R3 Report
AAMI Foundation HTSI Key Points Checklist
ECRI Strategies to Improve Monitor Alarm Safety
Assessment Tools/Strategy Documents:
VHA patient Safety Assessment Tool (PSAT)
AACN Alarm Management ActionPak
Device Worksheet
Pre-Change Assessment Survey etc.
HTF National Clinical Alarms Survey
Evidence based indications for cardiac monitoring
Interdisciplinary Team Member Involvement Options:
Clinical Engineering
CNS
Nursing Director for each clinical area
Physician Champion for each clinical area
Quality
Nurse Manager
Other professionals at library for data pull etc.
Nursing Informatics at library
(Suggest to utilize Interdisciplinary Team to: assist in steps of project,
CNS Competency
Direct Care, Consultation, Systems
Leadership, Collaboration,
Coaching, Research, Ethical
Decision-Making/Moral Agency
and Advocacy
NACNS Alarm Fatigue
How do I Start Checklist
i. Onboarding
ii. Ongoing
4. Staff attitudes / perceptions
5. HTF survey
6. Patient outcomes
a. Organizational data on alarm
events
Measure
Pre-Change Data Measurement Examples:
Alarm Event Data-Coordination with
Facility/IT
(alarm frequency etc)
Rapid Response Team/Code Team
Event related data
HCAPS-Quiet at Night Data
Pre-Change Assessment
o Overall # of alarms
o % nurses customizing alarms
o % of high, medium, low, and
technical alarms
Survey staff on perceptions /
attitudes
Staff knowledge
Analyze
Identify goals: determine how process
changes will affect process results.
Analyze Data from Measure section
Evaluate and Prioritize areas for
improvement
provide support, approve process steps, approve plan etc)
Metrics-consider:
clinical alarms
safety
staff education/competencies,
surveys/perceptions
patient outcomes
Resource: See Crosswalk
Consultation, Systems Leadership,
Collaboration, Research, Ethical
Decision-Making/Moral Agency
and Advocacy
Resource: See Crosswalk
Consultation, Systems Leadership,
Collaboration, Research,
NACNS Alarm Fatigue
How do I Start Checklist
Design
Resource: See Crosswalk
Direct Care, Consultation, Systems
Leadership, Collaboration,
Coaching, Research, Ethical
Decision-Making/Moral Agency
and Advocacy
Pilot Study Units to monitor change
Implement changes
Resource: See Crosswalk
Direct Care, Consultation, Systems
Leadership, Collaboration,
Coaching, Research, Ethical
Decision-Making/Moral Agency
and Advocacy
Work out details of change to be
implemented
Detail which alarms to change and
the process to implement the
change.
Include nurse related educational
needs for pilot. (staff
education/competencies)
Include dates/times to monitor data
Strategies for Clinical Alarm Management:
Defaults
Escalation
Customization
Evidence based use of monitoring
Clarify accountability
Policy development
Verify
PDSA Cycle on pilot units
Outcomes:
o Evaluate goals for success
 Overall # of alarms
 % nurses customizing
alarms
 % of high, medium,
low, and technical
alarms
Survey staff on perceptions /
attitudes
National Association of Clinical Nurse Specialists
Alarm Safety Crosswalk
Table 1
Organization
AACN
AAMI
ECRI
Hopkins
TJC
Healthcare Technology Foundation
(HTF)
Website / Resource
http://www.aacn.
org
www.aami.org
https://www.e
cri.org
Cvach Article
Graham Article
http://www.jointcommission.org
www.thehtf.org
Spotlight on Success: Johns Hopkins improves clinical
alarm safety with escalation algorithms.
Free
Free
Free
Reinforce and standardize nursing education on
monitoring skills.
NPSG 6: Reduce harm associated with clinical alarm
systems
No
Create a monitor competency checklist that reinforces
the practical elements regarding alarm management and
ensures that nursing staff is capable of monitoring
patients effectively.
No
No
NPSG 6: Reduce harm associated with clinical alarm
systems
No
Prepare an inventory of alarm-equipped medical
devices used in clinical areas, and identify the default
alarm settings and the limits appropriate for each
care area.
No
Cost to Access to
online resources
Free
Free
Education
Recommendations:
Initial or ongoing
No
No
Webinars free
for members;
$249 for nonmembers
No
Competency:
No
www.aami.org
No
Type of Technology
with Alarms:
Technology
Assessment:
Any direction on
how to do a
technology
assessment?
Recommendations
for assessment of
current state?
1. Cardiac
monitors
2. Pulse
oximetry
3. Ventilator
s
4. Bed Exit
Alarms
No
Gap Analysis
Webinar: How
to Identify the
Most Important
Alarm Signals to
Manage
No
1. Alarm
Parameter
Inventory
2. Alarm
Inventory Grid
Sample
3. How to
Identify the
Most Important
Alarm Signals to
Manage:
No
No
No
Spotlight on Success: Johns Hopkins improves clinical
alarm safety with escalation algorithms.
Use smart alarms or alarm technology that incorporates
delays
Spotlight on Success: Johns Hopkins improves clinical
alarm safety with escalation algorithms.
Change ECG electrodes daily or when ECG tracings are
poor
Spotlight on Success: Johns Hopkins improves clinical
alarm safety with escalation algorithms.
NPSG 6: Reduce harm associated with clinical alarm
systems
Recognize the Contributing Conditions:
1. Alarm parameters were not set to actionable levels
2. Alarm thresholds were set too tight resulting in too
many false positives
3. Staff working in large clinical units did not have clear
accountability to respond to alarm conditions
4. Patient rooms with closed doors made it difficult for
staff to hear alarm signals
5. Too many duplicate alarm conditions desensitized staff
to alarm signals
6. Lengthy time-lags between installation of devices and
staff training on those devices did not allow for staff to
Identify the most important alarm signals to manage
based on the following:
National Clinical Alarms Survey
1. Input from the medical staff and clinical
departments;
2. Risk to patients if the alarm signal is not
attended to or if it malfunctions;
3. Whether specific alarm signals are needed
or unnecessarily contribute to alarm noise and
alarm fatigue;
4. Potential for patient harm based on internal
incident history;
1
National Association of Clinical Nurse Specialists
Alarm Safety Crosswalk
Table 1
Organization
AACN
AAMI
ECRI
Hopkins
TJC
become accustomed to the auditory alarm signals of new
equipment
Recommendations
for Defaults
Recommendations
for best practice
No
www.aami.org
www.aacn.org
Christiana
Hospital
No
Using data to drive alarm systems improvements.
Graham Article
Interventions to Improve Alarm Safety:
Evidence Based Practice Recommendations to decrease
alarm fatigue covering:
1. Technology
2. Hospital
3. Caregiver
Cvach Article
Address Special
Populations
(e.g., peds)
No
Children's
National
Hospital
No
Template for
reports; dashboards
AACN Alarm
Fatigue Materials
Children's
National
Hospital
No
Spotlight on Success: Johns Hopkins improves clinical
alarm safety with escalation algorithms.
No
Develop an alarm management policy or address alarm
management in an existing cardiac monitor policy.
Healthcare Technology Foundation
(HTF)
5.
Published best practices and guidelines.
No
No
1. To help reduce nuisance alarm signals, change
single-use sensors (i.e. ECG leads) according to
manufacturer's recommendations.
2. Assess whether the acoustics in patient care areas
allow critical alarm signals to be audible.
No
No
No
No
Spotlight on Success: Johns Hopkins improves clinical
alarm safety with escalation algorithms.
The Joint
Commission (TJC):
NPSG
No
No
No
No
NPSG 6: Reduce harm associated with clinical alarm
systems
1. R3 Report ı Requirement, Rationale,
Reference
2.VHA Patient Safety Assessment Tool
3. Work plan for the NPSG (Hyman):
http://thehtf.org/clinical.asp
CUSP
(Comprehensive
Unit based Safety
Program)
No
No
No
Utilized CUSP on participating units:
A five-step program designed to change a unit’s
workplace culture—and in so doing bring about
significant safety
improvements—by empowering staff to assume
responsibility for safety in their environment. This goal is
achieved by providing employees education, awareness,
access to organizational resources, and a toolkit of
interventions. Its five steps include:
1. Train staff in the science of safety
2. Engage staff to identify defects
3. Senior executive partnership/ safety rounds
4. Continue to learn from deficits
5. Implement tools for improvement.
No
No
Using Data to Drive Alarm System Improvements
2
National Association of Clinical Nurse Specialists
Alarm Safety Crosswalk
Table 1
Organization
AACN
AAMI
ECRI
Hopkins
TJC
Healthcare Technology Foundation
(HTF)
Change Strategies
Gap Analysis
No
No
No
No
No
Order Sets
No
www.aami.org
No
No
No
No
Resources
AACN Alarm
Fatigue Materials
www.aami.org
www.aami.org
The Joint Commission Sentinel Event Alert, Number
50, April, 2013
TJC Sentinel Event Alert. Alarms
Clinical Alarms Management and Integration
Forms, templates,
data formats
AACN Alarm
Fatigue Materials
www.aami.org
www.aami.org
Using Data to Drive Alarm Systems Improvements
Resource Guide: Risky Business
Conducting Proactive Risk Assessments: Joint
Commission Resources
Quality & Safety Network
Strategies on how
to obtain monitor
data
No
No
No
Recommended data to obtain:
1. # Of high / medium / low priority and technical alarms
over a defined period
2. Average duration of alarms
3. Average daily census and average daily census on
telemetry
Spotlight on Success: Johns Hopkins improves clinical
alarm safety with escalation algorithms..
No
No
Media Available
Webinars, voice
over PPT, videos
Webinars
Webinars
Resources
No
No
Joint Commission webinar on Alarm Safety (May 1,
2013)
TJC Alarm Webinar Transcript
No
1. NTI Action Pack:
2. Fault Tree Analysis of clinical alarms
(Hyman) http://thehtf.org/clinical.asp
3
National Association of Clinical Nurse Specialists
Alarm Safety Crosswalk
Table 2: Alarm Fatigue Literature
Article
Association for the
Advancement of Medical
Instrumentation. (2011). A
siren call to action.
Design/Purpose
White paper of
recommendations from
AAMI Alarm Safety Summit in
2011.
Sample/Setting
Measurements/Instruments
Summit participants included
AAMI; FDA; TJC; ACCE; and ECRI
Strengths and Weaknesses
Relevance to Problem
Established 7 clarion themes, a
call to action to eliminate harm
related to alarms.
Strengths:
1. Clarion themes are inclusive;
include the challenge, the priority
action, and accountability.
2. Short term / long term solutions
Weaknesses:
1. Lack of dissemination
2. Document is complex
Addresses broad spectrum of
alarm safety issues.
More than 30% of all telemetry
days did not meet accepted
indications for monitoring
The incidence of significant
arrhythmia on a day where the
patient was not-indicated for
monitoring was extremely
small 3.1 out of 100 telemetry
monitored days
Telemetry monitoring can be
expensive. It is estimated to
cost $53.00 per patient per day
for telemetry; conservative
estimates assume for 400 bed
hospital patients with no
indication for monitoring can
cost hospital up to $250,000
per year.
Several studies have
demonstrated that the majority
of alarms created by patient
monitoring systems have no
clinical relevance
Strengths: large study of four
different hospitals; findings of the
study reveal similar trends in
monitoring utilization among
organizations
Weaknesses: economic analysis
was limited; it only included cost of
staff monitoring. Indirect costs
were not included for maintenance
of equipment or potential outflow
of patients needing telemetry beds
Time attending to alarms of
non-indicated monitoring
patients takes time and
attention away from patients
in need of monitoring.
Reducing over-monitoring
reduces costs and improves
safety
Level III
Grade B
Strengths: Table of literature
included with clear description of
each article
Weaknesses: Search strategy,
inclusion/exclusion criteria not
included
Level V
Grade C
Skin preparation done by using
One Step Skin Prep or the ECG
Prep Pads used once
significantly decreased skin
potentials by 2.3 mV and 3.3
mV respectively. There was no
significant difference in the
control group and the group in
which ECG Prep Pads were
used five times.
Strengths: Large study sample of
120 individuals
Weaknesses: skin preparation on
arms, and in laboratory not
The purpose of this article
was to present the current
issues and significance of
alarm fatigue within the ICU
environment
This article was included
(despite a large focus on
smart alarms), because it
discussed how human
factors are just as important
as engineering factors to
minimize alarms
***Landmark study used in
AACN ECG monitoring
recommendations and AHA
guidelines on ECG
monitoring (Drew et al.,
2004).
Clarion themes, challenges,
and priority actions
established by experts.
Benjamin et al., (2013), Impact
of cardiac telemetry
monitoring on patient safety
and cost.
Quality Improvement
Analysis of 1095 adult patients
with cardiac telemetry on
medical surgical and progressive
units (non-ICU), at 4 teaching
hospitals
Retrospective analysis of 1095
monitored telemetry patients
Researchers reviewed total days of
telemetry monitoring, incidents of
arrhythmias, adherence to guidelines
for ECG monitoring and adherence to
appropriate discontinuation of
telemetry
Total days of telemetry measured
Borowski et al., (2011).
Reducing False Alarms of
Intensive Care OnlineMonitoring Systems: An
Evaluation of Two Signal
Extraction Algorithms.
Review of medical device
alarms
The purpose of the article
was to present the current
situation regarding clinical
alarms and their problems in
intensive care such as lack of
clinical relevance, and alarm
fatigue
Review of 10 key articles based
on the workshop titled “Too
many alarms? Too few alarms?
Organized by the section patient
Monitors and the Workgroup
Alarms of the German
Association of Biomedical
Engineering
th
Workshop held November 25 ,
2009
Research themes:
Ergonomics and human factors
engineering could improve clinical
effectiveness and usability of alarms
Alarm algorithms can be used to
optimize alarm modalities, and combine
existing data into smart monitors
Intelligent alarm systems are needed
for a higher level of abstraction and
suppression using alarm validation
Clochesy, Cifani, & Howe,
(1991). Electrode site
preparation techniques: a
follow-up study.
Comparison of electrode site
preparation techniques
A posttest-only control group
design was used to study the
effect of electrode site
preparation techniques on
reducing electrical potential
across ECG skin electrodes
One hundred twenty healthy
volunteers were randomly
assigned into one control and
three treatment groups of 30
subjects each.
The three treatments were One Step
Skin Prep used once, ECG Prep Pad used
five times, and ECG Prep Pad used once.
To control for handedness, the skin
preparation site was randomly assigned
to either the left or right forearm
Retrospective analysis of
patient with cardiac
monitoring within 4 teaching
hospitals to quantify
telemetry over-monitoring
Level of
Evidence and
Grade
Results
Level III
Grade B
4
National Association of Clinical Nurse Specialists
Alarm Safety Crosswalk
Table 2: Alarm Fatigue Literature
Cvach, (2012). Monitor alarm
fatigue: An integrative review.
Integrative clinical review
investigating the clinical
problem of alarm fatigue
Review included 72 articles
related to alarm management
and alarm fatigue
Cvach, Biggs, Rothwell, &
Charles-Hudson (2013). Daily
electrode change and effect
on cardiac monitor alarms: an
evidence-based practice
approach.
Quality improvement study
Purpose of the study was to
determine if daily electrode
changes reduced number of
cardiac monitor alarms in
acute care unit
2 different adult acute care units
at John Hopkins:
15 bed medical progressive care
unit (MPC).
25 bed cardiology care unit (CCU)
(combined step-down and ICU
beds)
Drew et al., (2004). Practice
standards for
electrocardiographic
monitoring in hospital
settings.
Clinical guideline
Standards specifically for
hospitalized patients; both
children and adults
Purpose of the guideline is to
provide standards for ECG
monitoring within the
hospital setting
Major themes:
Excessive alarms have detrimental
effects on staff; distrust in monitoring
that leads staff to disable alarms
Nurse response to alarms is matched by
the perceived accuracy of the alarm
Alarm audibility; humans can only
distinguish a small number of audible
noises at one time.
Technology can be used to improve rate
of alarms; delays, adjusting default
settings, and customization of alarm
limits can be used to reduce false
alarms
Average number of alarms per day
measured pre and post intervention
Total number of alarms were measured
continuously for 8 days preintervention and 8 days after
intervention
Data (total number of alarms) retrieved
by clinical engineering
There are a variety of quality
improvement studies that have
been successful in reducing the
alarm burden with nursing
based strategies: skin prep,
education, customization of
alarms, and review of default
settings
Strengths: there is a large amount
of literature documenting the
significant number of false alarms
within the clinical setting
Reduction of total number of
alarms per day by 46%
Randomized clinical trials relative to
standard ECG monitoring are
nonexistent.
Guidelines offer
recommendations for ECG lead
placement, skin preparation,
and what patient
Strengths: Clear description
methodology. Skin preparation
included clipping hair, abrading skin
prep site, washing with soap/water,
and completely drying before
electrode change.
Daily electrode change between 8anoon.
All ST/QT alarms set for all patients
and used all default monitoring
parameters
Weaknesses: Lack of monitored
compliance of unlicensed staff. In
future have specific plan to hold
staff accountable to ensure daily
changes are occurring
Strengths: Guideline offers first and
only ECG standards based on
retrospective adverse outcomes for
monitored patients. Includes RCTs
Weaknesses: there are very few
RCTs related to monitoring
standards or appropriate
parameters, leads, or what patients
to monitor and for how long. Much
of the guideline is expert
consensus. Little information given
on disclosure of authors or
plans/tools/guides for
implementing the standards within
healthcare organizations.
Majority of the consensus is based on
expert opinions and research in the
field of electrocardiography.
A knowledge gap exists
regarding how to suppress
false alarms
Level III
Grade A
Daily change of electrodes
with skin preparation
resulted in fewer cardiac
monitor alarms (reduced
number of alarms by 46%)
Noted that increases in ‘lead
off’ alarms during electrode
change time due to techs not
pausing alarms during daily
electrode change. Alarms
are silenced when taking
patients off monitors for any
reason.
Level III
Grade B
Only published standards of
ECG monitoring
Level II
Grade B
An overall
score of 4/7
was based on
AGREE
Research
Trust (2009)
tool for
appraising
guidelines
Weaknesses: Most evidence related
to reducing alarms is from
observational studies. Very few
RCTs
5
National Association of Clinical Nurse Specialists
Alarm Safety Crosswalk
Table 2: Alarm Fatigue Literature
Edworthy, (2013). Medical
audible alarms.
Review of the available
research related to design of
auditory alarms in healthcare
Aim of the article it to
demonstrate that false
alarms for medical devices
are unacceptable and alarm
design principles must be
addressed
Literature searched specifically
for audibility and visual medical
alarms
Review examined 50 journal
articles, three books, and 100
conference papers
Feder & Funk, (2013). Overmonitoring and alarm fatigue:
For whom do the bells toll?
Expert Opinion/ Descriptive
review
Overview of literature
related to over-monitoring
Hospitalized patients both adults
and pediatrics
Funk et al., (2010).
Unnecessary arrhythmia
monitoring and
underutilization of ischemia
and QT interval monitoring in
current clinical practice:
Baseline results of the
Practical Use of the Latest
Standards for
Electrocardiography Trials.
Multi-site prospective
observational study
examining ECG monitoring
based on American Heart
Association’s standards for
ECG monitoring
Purpose is to determine if
patients are appropriately
monitored as ongoing efforts
to reduce clinically
insignificant alarms.
17 cardiac units in 17 hospitals
15 in the United States, one in
Canada and one hospital in Hong
Kong.
Hospitals were either academic
medical centers or community
hospitals, all received IRB
approval, and all organization
treat medical and cardiac surgical
patient populations
Funk et al. (2013). An
alarming rate of unnecessary
monitoring in the Practical Use
of the Latest Standards of
Electrocardiography (PULSE)
trial.
Poster
Analysis of data from PULSE trial:
multisite RCT addressing ECG
monitoring practices
Evaluation of appropriate use
of ECG monitoring
Main themes:
There are a high number of false alarms
There is a lack of standardized alarm
philosophy and mapping of alarms to
provide end users and understanding of
alarm priorities
Audible alarm design can be improved;
users cannot interpret and understand
the vast number of melodic tones of
alarms
IEC-60601-1-8 is an international
standard aimed at harmonizing medical
device alarms. This provides a
philosophy of alarms to prevent
proliferation of alarms that determines
the success of alarms
Presents articles that suggest
monitoring does not contribute to early
detection of clinically relevant
arrhythmias, decrease long term
mortality or alter treatment of patients;
instead it is distracting and contributes
to the high number of false and
irrelevant alarms.
No literature to support telemetry
monitoring as a method to prevent,
detect, or improve survival for cardiac
arrest
Medical records were reviewed by 3
experienced ICU nurse researchers to
determine if the patient had either a
Class I or Class II indication for
monitoring. Furthermore, the
researchers reviewed monitoring for
QTc/ST segment monitoring
5 day visit to each unit
Prospective medical records review for
class I and class II indications for ECG
monitoring.
4,678 observations on 3,250 patients in
17 hospitals in cardiac care units
There are a high number of
false alarms and reduction in
false alarm rates means that
the design of audible alarms
must be improved.
Standardization of audible
alarms is best practice.
Strengths: Provides unique
perspective of alarm management
from biomedical sciences
perspective and the ability of
humans to detect audible alarms
Weaknesses: Narrative review;
search strategy, inclusion criteria
not included
Practical alarm management
strategies such as delays are
likely to reduce the rate of
false alarms
There is a need for
standardization of alarm
principles, audibility, and
alarm ergonomics
Level V
Grade C
Rationale that more monitoring
leads to more alarms without a
significant improvement in
outcomes for many patients.
Based on information from
literature, 35% of all monitored
patients have no indication for
monitoring
Strengths: Rationale for not
supporting widespread monitoring
supported by retrospective studies
examining survival and outcomes
with/without telemetry monitoring
Weaknesses: No RCTs comparing
outcomes of monitored and
unmonitored patients. Recognition
that practice standards are now
outdated; need updated standards
based on new monitoring
technology
Strengths: Large multisite study.
Uses clear definitions for
indications for monitoring from
AHA standards. Patients randomly
selected. Also tracked use of ST
segment and QTc monitoring that
are known to detect serious clinical
events.
Weaknesses: Authors suggest that
the staff of the study and may have
changed their behaviors because
they knew the study was in
progress (Hawthorne Effect)
Over-monitoring is a
contributing factor to alarm
fatigue and the high number
of false alarms
Level V
Grade B
Monitoring is inappropriate
and can result in
unnecessary alarms:
There is over-monitoring for
patients with no indication
for monitoring
Patients with indication for
ST segment or QTc
monitoring are under
monitored
Level III
Grade B
Over monitoring leads to
unnecessary alarms.
Eliminating unnecessary
monitoring will decrease the
alarm burden and decrease
sentinel events related to
alarm fatigue.
Level II
Total of 1816 patients
89.9% patients with indication
for monitoring were monitored
84.9% of patients with no
indication for monitoring were
monitored
Of patients with indication for
ST segment monitoring, 34.5%
were monitored with ST
segment monitoring
Of patients with indication for
QTc monitoring, only 21.4%
had a documented QTc interval
within the past 24 hours
26% of patients had no
indication for monitoring
Grade B
6
National Association of Clinical Nurse Specialists
Alarm Safety Crosswalk
Table 2: Alarm Fatigue Literature
Gorges, Markesitz, &
Westenskow, (2009).
Improving alarm performance
in the medical intensive care
unit using delays and clinical
context.
Graham & Cvach, (2010).
Monitor alarm fatigue:
Standardizing use of
physiological
monitors and decreasing
nuisance alarms.
Observational study
Observing monitor alarms in
ICU; study of how many
alarms are observed to be
ignored by staff and how
many are actionable. After
observation, determine how
many alarms could have
been avoided by an alarm
delay.
The purpose of the study was
to observe alarms in the
Medical ICU to identify
methods for reducing the
number of false alarms by
using delays and finding
correlations between alarms
and clinical context
200 hours of direct staff
observation in a Utah 12 bed
Medical ICU
Quality improvement project
Purpose of the study was to
determine if RN adjustment
of alarm limits on monitors,
changes to default alarm
settings, and involvement of
interdisciplinary monitor task
force team reduced number
of monitor alarms and
improved noise level of the
unit.
15 bed Medical ICU
John Hopkins Hospital
Data from January 2006 to June
2007
Number of alarms were recorded as
well as the number of tasks performed
in response to alarms
1214 alarms occurred
2344 tasks were performed in response
to the alarms
-On average 6.07 alarms occurred each
hour
-41% of alarms were ignored
-Alarms were active for an average
duration of 17 seconds before acted on
-36% of the alarms were ineffective
A 14 second delay would have
eliminated 50% of the ignored
alarms
A 19 second alarm would have
eliminated 67% of all alarms.
Suctioning, washing,
repositioning, and oral care
caused 152 ignored or
ineffective ventilator alarms
Clinical engineers counted all cardiac
alarms for an 18 day period both pre
and post intervention.
4 types of alarm categories:
Crisis: Asystole VT, VF, bradycardia
Warning: tachycardia, bradycardia
Advisory: pulse oximetry and PVCs
Message: irregular
System warning: lead failure or
arrhythmia
Study also measured pretest/posttest
RN questionnaire on monitor
knowledge and perception of unit noise
level
Critical monitor alarms were
reduced by 43% from baseline
data due to adjustment of
alarm limits, and
implementation of an
interdisciplinary monitor policy.
Pretest: 83% of nurses changed
alarm parameters when a
patient condition changed,
Post intervention 94% of RNs
reported to change alarm
parameters to individual
patient needs
Pretest: 78% of nurses changed
alarm parameters at the
beginning of their shift.
Post: 94%
Noise level: Rated 1-5 (1= low,
5=high noise level)
Pre: 4.0/5 unit overall noise
Pre: 3.1/5 noise from monitors
Post intervention: 3.5/5 unit
overall noise
Post 2.97/5 noise from
monitors
Strengths: Demonstrates that
introduction of an alarm delay
improves alarm reliability at the
expense of lengthening response
time. Appeared that staff respond
selectively to alarms or wait before
responding. Unique perspective for
classifying alarm based on response
rather than event triggering the
alarm
Weaknesses: observation based;
subjective of context awareness of
alarms that is difficult to define
Strengths: breakdown of all alarms
before and post intervention in
table.
-No interpretation of alarms as
false/true
-Study included cardiac telemetry
alarms and pulse ox alarms.
Weaknesses: Surveys on alarm limit
adjustment compliance and unit
noise level may not be accurate as
survey not required and was on
volunteer basis for RNs. Single unit
study
Many alarms are false or
provider induced.
Introducing alarm delays and
purposefully silencing alarms
during routine care (such as
suctioning) can make alarms
more reliable and elicit a
more timely response,
reduce workload, reduce the
noise pollution, and
potentially improve patient
safety.
Level III
Grade B
RN adjustment of alarm
limits is starting point in
reducing number of
physiologic monitor alarms
Nurses must be trained to
adjust alarm limits. RNs
were advised to widen alarm
limits for blood pressure and
heart rate by +/- 20 points of
the patient’s normal values.
Level III
Grade B
7
National Association of Clinical Nurse Specialists
Alarm Safety Crosswalk
Table 2: Alarm Fatigue Literature
Gross, Dahl, & Neilsen, (2011).
Physiologic monitoring alarm
load on
medical/surgical floors of a
community hospital.
Quality Improvement Study
Purpose of the study was to
determine if it was possible
to significantly reduce the
number of physiologic
monitor alarms for med/surg
patients by adjusting alarm
limits (HR high alarm from
120 to 130 and pulse
oximetry low alarm from 90
to 85)
A 79 med/surg beds of
community hospital located in
urban Arizona
Data collected over 1 year time
period
Retrospective evaluation of alarm
frequency from April 2009 to January
2010
Before alarm limit adjustment, the
average rate of alarms was 95.6 alarms
per patient per day.
For all patients, the average hours of
monitoring were 16.5 hours/patient.
Reduction of alarm frequency
by 50% by adjusting high HR
alarm from 120 to 130
Reduction of pulse ox alarm by
36% reducing the Sp02 alarms
from 90% to 85%.
Harris, Manavizadeh,
McPherson, & Smith, (2011).
Do you hear bells:
The increasing problem of
alarm fatigue.
Quality Improvement
Descriptive study outlining
one organization’s strategies
for heightening awareness of
alarm fatigue to reduce
alarm burden
988 bed academic community
hospital with Magnet designation
Three hospital entities sites
The organization developed a
multidisciplinary team of staff,
biomedical engineers, and educators to
strategize ways to reduce the alarm
burden
The team provided education to the
bedside staff regarding alarm fatigue.
Staff also received education on the
monitor capabilities.
Education on monitoring capabilities
was in a CD format for staff to review
The Joint Commission, Patient
Safety Advisory Group. (2013,
April 8). Sentinel Event Alert.
Medical device alarm safety in
hospitals.
Regulatory Safety Alert
Sentinel event (SE) database;
FDA Maude database.
Identified risks associated with
clinical alarms based on reports
in sentinel event database.
Information from sentinel event
database.
The team analyzed baseline
alarm data, reviewed hospital
protocols for alarm
management.
Discovered in this process that
staff did not know how to use
monitors to their full potential;
no training was offered on
monitoring. Preceptors taught
new staff what they knew
about monitors. No formal
education
After education for staff (6
months) the alarms were reevaluated: the ICU had a 30%
improvement in alarm burden
and a 12% reduction in alarms
was noted on progressive units
Recommendations / potential
strategies for improvement
The Joint Commission (2013).
Spotlight on Success: Johns
Hopkins improves clinical
alarm safety with escalation
algorithms.
Interview w/ clinical expert
about QI project on
escalation strategies for
alarm safety
Discussion of QI project from
Johns Hopkins; introduced alarm
escalation
New wireless device to create
escalation process for clinical alarms
Outside of the escalation QI
project:
1. Identified 7 strategies to
improve alarm safety
2. 53% decrease in high
priority alarms
3. 23% decrease in duration of
high priority alarms
Strengths: True and false alarm
criteria specifically defined
-Raw data provided for true alarms,
false alarms, and uncertain alarms.
-Alarms reviewed by two
independent clinical researchers for
validity, in case of disagreement a
third clinical ‘judge’ was used
-Included both telemetry and pulse
oximetry
Weaknesses: Only 34% of HR
alarms and 63% of pulse ox alarms
considered true alarms continue to
work on sensitivity/specificity of
clinical alarms.
Strengths: Article provides
discussion of the challenges to
implementing a change at a large
hospital with multiple entities.
Weaknesses: The study did not
provide methodology for collecting
baseline alarm data or how or
when the follow-up data collection
was completed. No raw data is
provided only two percentages
indicating there was a reduction in
the alarms. Sample size is not
provided.
Current alarm limits from
Philips monitors appear to be
too tight for non-ICU patient
and contribute to an
unnecessarily high alarm
load.
-Small adjustments in clinical
alarms limits significantly
reduce alarm load
Studied only critical or high
priority alarms for telemetry
Level III
Grade B
A reduction in alarm burden
was achieved though
educating nurses about
alarm fatigue, customization
of alarm parameters, and the
capabilities of the monitors.
Level VI
Grade C
Strengths: clear data &
recommendations.
Raised awareness across
healthcare about the risks
associated with the
overwhelming number /
volume of alarms.
Weaknesses: Industry experts
believe reports underrepresent
actual number of events.
Strengths: 7 strategies
recommended are within the scope
of most organizations to integrate
immediately.
Weaknesses: Nomenclature is
vendor specific for the alarms.
Escalation strategy requires
purchase of wireless devices
Seven strategies are clear
and can make a significant
impact without structural
changes / significant
resources.
Introduction of wireless
devices would be more
challenging.
Level VI
Grade C
8
National Association of Clinical Nurse Specialists
Alarm Safety Crosswalk
Table 2: Alarm Fatigue Literature
Jonasson, (2007). A
prospective study on the
relevance of skin preparation
for
noise, impedance and ECG
intervals among healthy
males.
Prospective study
Study designed to determine
relevance of ECG skin
preparation to reduce noise
and impedance (artifact)
among healthy males
22 healthy male test subjects
June 2006
Halmsted, Sweden
Korniewics, Clark, & David,
(2008). A national online
survey on the effectiveness
of clinical alarms.
Descriptive Analysis based on
a national survey to identify
the problems associated with
alarms in hospitals
Medina, Clochesy, & Omery,
(1989). Comparison of
electrode site preparation
techniques.
Comparison of electrode site
preparation techniques
A posttest-only control group
design
Melendez & Pino, (2012).
Electrocardiogram
Interference: A Thing of the
Past?
Quasi-Experimental design
ECG interface was controlled
and studied in a laboratory
environment and then tested
in the clinical environment
Purpose of the study is to
find the best method to
reduce interference of
physiologic waveforms from
electrodes to improve alarm
reliability
Researchers received survey
results from t 1327 healthcare
workers’=
94% worked in acute care
hospitals
51% were RNs
31% worked in ICU
Survey was developed by a 16
member task force of nurses and
clinical engineers
60 health volunteers were
randomly divided into one
control and two treatment
groups of 20 subjects each
Within each group, the skin
preparation for the ECG
electrodes (treatment) was
further assigned randomly to
either the right or left forearm.
In the laboratory: a controlled
electrode impedance mismatch
was simulated on one patient
with various skin preparations on
the left leg.
In the clinical setting
ECG interference was tested in
the cardiac stress test laboratory
and the electroencephalography
(EEG) laboratory
Male subjects wearing ECG monitors
were recorded over 5 minute time
periods at 5 time points at 3 separate
24 hour visits with different types of
ECG skin prep
1.
No skin prep
2.
Abrasion only
3.
Abrasion and alcohol skin prep
At the end of each visit, i.e. 24 hours
after electrode application, each
subject was questioned regarding
itching from the electrodes on a fivestep scale of no itching, mild, moderate,
severe, and very severe itching.
Artifact measured in ECG impedance
and ECG amplitude.
-Sandpaper, grain 400, was used for
skin abrasion
- Skin impedance was to be measured
prior to each ECG recording period in
leads V2 and V3 using a Prep-Check
Electrode Impedance Meter
81% reported alarms disrupt care
78% distrust alarms and disable them
>90% agreed that that there is a need
for prioritized and easily differentiated
audible and visual alarms
Skin preparation with One Step Skin
Prep, ECG prep pads, or no skin
preparation
Interference from electrodes on
monitoring was measure using
impedance monitors.
Interference was measured in the
laboratory setting on test patients with
test equipment and then further tested
in real clinical settings
Skin preparation by abrasion
showed statistically significant
reduction in skin impedance
and noise for all ECG leads
(compared to no skin
preparation)
Skin cleansing with alcohol is
not warranted.
Strengths: All statistical data
included in article
-Controlled study environment
-Documentation of body size,
weight, BMI
-Impedance measured in
individuals leads
Weaknesses: Lack of randomization
-Small sample size
-Skin itching and irritation
did not differ between three
skin preps
-Hair was trimmed on all
patients, no study findings
on clipping vs. shaving hair
for optimal electrode
adhesion
Level III
Grade B
The survey results suggest that
there is a need for
Equipment redesign
Clinicians who take an active
learning in how to use
physiologic monitoring
correctly
Hospitals must recognize the
complexities of managing
clinical alarms
Skin preparation by using One
Step Skin Prep significantly
decreased skin potentials (1.90 mV) whereas the group in
which ECG Prep Pads were
used and the control group had
no significant change
Strengths: one of very few studies
describing the perspective of the
bedside staff in dealing with the
alarm burden
Weaknesses: convenience sample
of respondents
Surveys may not provide the most
accurate data related to a subject
area
It is necessary to provide
staff with education and
policies related to alarm
responsiveness and
awareness of alarm fatigue
Level VI
Grade C
Strengths: randomized trial
Weaknesses: testing only in
laboratory setting on patient
forearms. Small sample size
***Landmark study used in
AHA guidelines on ECG
monitoring (Drew et al.,
2004)
Level II
Grade B
Skin preparation with pumice
was more effective that skin
adhesive or alcohol
Dry electrodes that are not
kept in manufacturer packaging
causes the electrodes to dry
and lose effectiveness
Train clinical and technical staff
on what causes electrode
interference
Strengths: Interference was
measured using with impedance
meters to create objective
measurement of interference
Weaknesses: Sample size unknown.
All skin preparations tested are not
included in the study methodology.
Article describes a ‘trial and error’
technique to slowly changing out
products, skin preparations, and
electrodes until interference was
reduced
With consistent skin
preparation and testing of
electrodes with impedance
meters, interference can be
eliminated in some clinical
settings including the
operating room
Simple changes such as fresh
electrodes and skin
preparation make potentially
dramatic changes in
performance of ECG
monitors
Level III
Grade C
9
National Association of Clinical Nurse Specialists
Alarm Safety Crosswalk
Table 2: Alarm Fatigue Literature
Phillips, (2006). Clinical
alarms: Complexity and
common sense.
Expert Opinion/
Descriptive analysis
The article provides a guide
from the acute care team in
evaluating alarm systems in
the clinical environment
Review of components of
alarm safety programs
Includes strategies for review of
alarms and evaluation of alarm
burden in all acute care settings
Article provides assessment tools for
use in evaluation of organizational
alarm systems
Steps in evaluation include:
An environmental assessment
Assessment of alarm response; who is
responsible for responding to and
assessing alarms
Assessment of alarm system problems
from environmental, user, technical,
and other categories.
Assessment of alarm system
will guide clinical policies
related to
Initiation and prioritization of
alarms
Policies related to silencing and
disabling alarms
Bed to bed notifications
Bedside device integration
How to deal with ‘lead off’
Volume of alarms
Strengths: article provides an
evidence based tool kit for
assessing alarms within an
organization and strategies for
reducing alarm burden
Weaknesses: No guides for
appropriate default settings or
methods for customizing individual
patient alarms
Sendelbach, (2012). Alarm
fatigue.
Literature Review
Overview of phenomenon of
alarm fatigue and alarm
management literature
Includes review of total number
of alarms measured in a variety
of clinical settings: emergency
departments, critical care,
operating rooms, and
medical/surgical units.
Based on the current literature, there is
a range of only about 0.6%- 8% of
alarms that are clinically significant
Strengths: comprehensive analysis
of the issue of alarm fatigue and
task forces working on reducing
false alarms
Weaknesses: only offers overview
of literature and no
recommendations for individual
organizational alarm improvement
strategies
Sendelbach, S., & Funk, M.
(2013). Alarm Fatigue: A
Patient Safety Concern.
Clinical review
Information from TJC, ECRI, HTF,
AAMI, AACN related to alarm
safety
Major themes:
1. Described alarm fatigue: how, why,
impact
2. Discussed recommendations by each
organization to combat alarm fatigue
Based on the high rate of false
alarms there are a variety of
practice alerts to address alarm
fatigue:
Biomedical engineering to
consider smart alarms and
alarm mapping to reduce
alarms
Nursing policy and procedure
for skin preparation, ongoing
education, and alarm
customization are
recommended
Hospitals must educate staff
and pay attention to the
default settings and monitoring
capabilities of organizational
software
Recommendations:
Alarms need to be sensitive
and specific.
Interventions to decrease
alarm fatigue have not been
rigorously tested.
Strengths: Proposed future
research in false alarms; nonactionable alarms; appropriate use
of monitoring; processes of care
Identified alarm systems that
are supposed to help, but
actually increase risk because
of alarm fatigue
Siebig et al., (2010). Intensive
care unit alarms: How many
do we need?
Observational study to
validate the number of a
cardiac alarms among
critically ill patients to
determine the relevance of
alarms
Medical intensive care unit at a
University Hospital
from Jan 2006 to May 2007
Recording of 982 hours of alarm
data
982 hours recorded by video and
observed by a physician
Video recordings were annotated for
alarm relevance and technical validity
Physiologic data from monitors was
recorded at 1 second intervals that
were extracted from the monitoring
network software
Within the 982 hours there
were a total of 5934 alarms
40% of alarms did not describe
the patient condition correctly
68% of alarms were caused by
staff manipulation
Only 15% were true alarms
Most (70%) of alarms were
simple threshold alarms
45% were related to arterial
blood pressure monitoring
from arterial lines
Strengths: Comprehensive analysis
of each type of alarm and
validation by observing physician
related to the relevance and clinical
‘trueness’ of each alarm
Weaknesses: Possible bias
introduced by individual
interpretation of clinical relevance
of alarms. Other studies had 2-3
clinical observers to arrive at group
consensus of alarm relevance
Suggestion that because
most alarms are due to
simple thresholds
customization of alarm limits
may significantly reduce the
number of false alarms
It is suggested that
customization for alarm
parameters could be
targeted around +/- 20% of
‘normal’
Identify strategies to
decrease alarm fatigue
Clinical alarms are important
in the healthcare
environment but it is
essential for organization to
make efforts to improve the
reliability of alarms.
Standardization of alarm
management techniques is
critical to creating alarm
systems that are safe
** Reviewing the previous
shifts alarm customization is
essential to creating a
cultural norm to customize
alarms
Provides an overview of the
clinical problem of alarm
fatigue and safety concerns
related to the high number
of false alarms in the current
healthcare environment
Level VI
Grade B
Level V
Grade B
Level III
Grade B
10
National Association of Clinical Nurse Specialists
Alarm Safety Crosswalk
Table 2: Alarm Fatigue Literature
Urden, L. D., & Stacy, K. M.
(2011). Clinical nurse
specialist orientation: ready,
set, go!
Qualitative study
Welch (2011). An evidencebased approach to reduce
nuisance alarms and alarm
fatigue.
Quality Improvement Study
Study to determine if
adjustment of alarm
thresholds reduces number
of alarms for pulse oximetry
monitors in post-surgical
patients.
Retrospective analysis of
alarm load pre/post
intervention.
Quality Improvement Study
Study to determine variables
that would safely reduce
noncritical telemetry monitor
alarms by altering
manufactures default alarm
settings
Whalen et al., (2013). Novel
Approach to the Management
of Clinical Alarm Fatigue.
CNS team at Magnet community
hospital
Design the CNS orientation
process using the 3 spheres
of influence
1. Review of the literature
2. Initial competency validation
checklist for CNS
Development of evidence
based tool for orientation of
the new CNS or CNS new to the
hospital
Strengths: Evidence based tool for
orientation of CNS
Outlines the spheres of
influence of the CNS
Level VI
Grade C
Weaknesses: External validity is
questionable, only done in one
setting.
Post-surgical patients on 36 bed
floor over 11 month time period
Baseline data: most common alarm is
SpO2 less than 90% that alarmed 4.4%
of the entire monitoring time equating
to 63 minutes per patient per day
Intervention (reducing alarm threshold
to 89, 88, 87, 86 or 85) and delaying the
alarms at times ranging from 5-15
seconds
Decreasing alarm thresholds
from 90% to 88% decreases
alarms by 45%
Reducing the low alarm
threshold from 90% to 85%
decreases alarm rate by 75%
Increasing alarm delays from 5
seconds to 15 seconds reduces
alarm rate by 70%
Strengths: Large sample size,
measurements over extended
period of time.
Weaknesses: Only measured alarms
of pulse oximetry. No discussion of
alarms due to disconnections of
cable, loss of connection due to
application of sensors to pulse ox
alarms.
Altering alarm limits or
slightly delaying alarms is a
cost effective approach to
reducing burden of alarm
fatigue
Not all institutions ok with
lowering alarm limits by
large amounts in critically ill
or acutely ill patients.
Level III
Grade B
General medical-surgical unit at
Boston Medical Center
24 bed pilot unit
2 week time period
Alarm data, nurses response to alarms,
unit noise in dB, and patient
satisfaction, and nursing perception of
noise were measured
Baseline data: 87,823 audible alarms
per week on the unit. After
intervention: 9967 alarms in one week
on the pilot unit.
Default alarm settings altered and
education for RNs to customize alarms
Nursing staff perception of noise via
anonymous survey
Overall an 89% reduction in
audible alarms was achieved on
the pilot unit (t = 8.84; P < .001)
The incidence of Code Blue
events decreased by 50%
Noise levels evaluated in
decibels from 54-90 dB preimplementation
Post-implementation noise
ranged from 60-72 dB.
Patient satisfaction scores
based on Press-Ganey. Nurse
domain rank increased by 15
percentile ranks, noise in room
increased by 12, promptness to
call lights increased by 39.
Overall rank increased by 31
Nursing perception of noise
increased from noise is
acceptable 0% of the time to
post-study of noise acceptable
64% of the time
Strengths: complete report of
changes to alarms, alarm
distribution and statistical
significance of alarm burden
pre/post study
Weaknesses: nursing satisfaction
post-implementation measured by
‘comments’ rather than established
tool
A significant reduction in
alarm burden can be
achieved without costly
resources or new
technology.
Incidence of safety events
was successfully decreased
and patient satisfaction
improved
Level III
Grade B
Articles Not Included in Literature Review that Provide Background Information
11
National Association of Clinical Nurse Specialists
Alarm Safety Crosswalk
Table 2: Alarm Fatigue Literature
Article
Association for the Advancement of Medical Instrumentation, (2011).
Design/Purpose
2011 Summit; a call to action for addressing healthcare alarms
Key stakeholders are identified and seven themes related to alarm
management are addressed
Descriptive analysis of technological communication strategies to
alert providers of critical alerts
Rationale for not including in Literature Review
Provides background and overview of medical device safety issues related to alarms. Summit
publication provides background information regarding the history of alarm fatigue, medical device
alarms, and significance of the problem.
Focus is primary on technology/smart alarm integration of monitoring equipment with pagers and alerts
to communicate alarms with bedside staff. Focus is on smart monitoring
Bush-Vishniac et al., (2005). Noise levels in Johns Hopkins Hospital
Descriptive analysis of noise levels in John Hopkins Hospital; particular
at night
Provides background evidence related to the problem of noise in hospitals and the noise that is
attributed to alarms and physiologic monitors
Emergency Care Research Institute (2011).
An organizational publication that regularly reviews healthcare
technology
Descriptive analysis/Expert Opinion related to the history of alarm
fatigue
An introduction into the top ten health safety concerns
Descriptive analysis of alarm fatigue
Newspaper article describing a highly publicized patient death
attributed to alarm fatigue
Expert opinion
Background information on tracking and evaluating medical device safety and safety issues related to
alarm fatigue
Provides background information and definition of alarm fatigue
Descriptive analysis examining the effects of nursing burnout on
patient outcomes
Literature review describing sources of noise in ICU environment
Background information related to the patient safety risks associated with nursing burnout
Descriptive analysis/ Expert opinion of risks associated with hospital
noise
Observational study quantifying the noise levels in hospitals
Background information related to alarms contributing to noise in hospitals
Bonzheim et al., (2011). Communication Strategies and Timeliness of
Response to Life Critical Telemetry Alarms
Hannibal (2011). ECG Challenges: Monitor Alarms and Alarm Fatigue
Keller (2012). Making clinical alarm management a patient safety priority.
Kerr & Hayes (1983). An “alarming situation in the intensive therapy unit.
Kowalczyk (2011). ‘Alarm fatigue’ linked to patient’s death.
Mazer (2012). Creating a Culture of Safety
Reducing Hospital Noise
Poghosyan, Clarke, Finlayson, & Aiken, (2010). Nurse Burnout and Ratings
of Quality of Care: A Six-Country Study
Pugh, Jones, & Griffith, (2007). The impact of noise in the intensive care
unit.
Wallis (2012). Alarm fatigue linked to patient death.
Yoder et al., (2012). Noise and Sleep Among Adult Medical Inpatients: Far
From a Quiet Night
Level I
Level II
Level III
Level IV
Level V
Level VI
Level VII
Grade A
High
Grade B
Moderate
Grade C
Weak
Background information related to safety of medical devices
Older article; provides background and history of alarm sensitivity and alarm fatigue
Background information related to alarm fatigue and patient safety
Background information. Description of noise in hospitals; what devices contribute to noise burden
Background information; alarms contributing to noise
Background information related to alarms and noise
Level of Evidence (Melnyk & Fineout-Overholt, 2011)
Systematic review & meta-analysis of randomized controlled trials; clinical guidelines based on systematic reviews or meta-analyses
One or more randomized controlled trials
Controlled trial (no randomization)
Case-control or cohort study
Systematic review of descriptive & qualitative studies
Single descriptive or qualitative study
Expert opinion
Grade Rating: Strength of Evidence (Melynk & Fineout-Overholt, 2005)
Reflects a high degree of clinical certainty and is based on availability of high quality level I, II, or III evidence.
Reflects moderate clinical certainty and is based on availability of level III and/or level IV evidence. There are some minor flaws or inconsistencies
Level V, VI, or V evidence. There is limited or low quality evidence; has limited or unknown effectiveness
12
FAQs on Alarm Management
Question
Nursing Practice
What are the best strategies to reduce the number of clinical
alarms?
For monitored units, how often do you review alarms? What
does your review include (i.e. arrhythmias, yellow alarms,
trends, alarm limits, etc.)?
Where do nurses document alarm review?
How can I support the appropriate use of telemetry? (or
June, 2014
Answer
Multifactorial:
Establish an inter-professional team to address alarm fatigue across all
environments of care
Conduct an inventory of alarm-equipped medical devices
Develop guidelines for alarm settings & tailoring of alarms
Provide proper skin preparation for EKG electrodes
Customize alarm parameters & levels on EKG monitors
Customize delay & threshold settings on O2 sat monitors
Provide initial & ongoing education about devices with alarms
Monitor only those patients with clinical indications for monitoring
http://www.aacn.org/wd/practice/docs/practicealerts/alarm-management-practice-alert.pdf
Managing Alarm Fatigue: New Approaches and Best Practices
Live Q&A: Alarm Management Implementation Revisited
Sendelbach,S. & Funk, M.(2013). Alarm fatigue: A patient safety concern. AACN Advanced
Critical Care, 24(4), 378-388.
Documentation is organization specific.
Consider patient acuity level
Determine priority of alarms (high, medium, low) and risk of death/unintended
consequences if unattended
Identify actionable alarms (requires clinical intervention or some type of action)
Identify non-actionable alarm signal (true alarms that do not require a clinical
intervention or action)
http://www.aami.org/meetings/webinars/HTSI/resources/10302013_Slides.pdf
http://www.aami.org/meetings/webinars/htsi/resources/12032013_Checklist.pdf
Sendelbach, S., & Funk, M. (2013). Alarm fatigue: a patient safety concern. AACN advanced
critical care, 24(4), 378.
Documentation is organization specific. Policies should guide:
Standardized location of information
What is included in the documentation (e.g., lead, rhythm interpretation, intervals,
alarm review, alarm limits)
Frequency of documentation
 How often the strip must be run, interpreted and posted
 How often documentation of the rhythm needs to be in the medical record
Evidence Based Practice:
FAQs on Alarm Management
make sure telemetry is not over-prescribed or implement a ”
telemetry use reduction project”) How can I encourage
physician buy-in?
June, 2014
Expert opinion and research recommend monitoring only those patients with
clinical indications for monitoring
Developing an alarm safety program helps identify the appropriate patients and
helps standardize the practice across clinical environments.
http://www.aacn.org/wd/practice/docs/practicealerts/alarm-management-practice-alert.pdf
http://www.aami.org/meetings/webinars/HTSI/resources/10302013_Slides.pdf
http://www.aami.org/meetings/webinars/htsi/resources/12032013_Checklist.pdf
Drew, B. J., Califf, R. M., Funk, M., Kaufman, E. S., Krucoff, M. W., Laks, M. M., & Van Hare, G.
F. (2004). Practice Standards for Electrocardiographic Monitoring in Hospital Settings An
American Heart Association Scientific Statement From the Councils on Cardiovascular
Nursing, Clinical Cardiology, and Cardiovascular Disease in the Young: Endorsed by the
International Society of Computerized Electrocardiology and the American Association of
Critical-Care Nurses. Circulation, 110(17), 2721-2746.
http://circ.ahajournals.org/content/110/17/2721.full.pdf+html
Feder, S., & Funk, M. (2013). Over-monitoring and alarm fatigue: For whom do the bells toll?
Heart & Lung: The Journal of Acute and Critical Care, 42(6), 395-396.
Funk, M., Stephens, K., May, J., Fennie, K., Feder, S., & Drew, B. (2013). An alarming rate of
unnecessary monitoring in the Practical Use of the Latest Standards of Electrocardiography
(PULSE) trial. Journal of the American College of Cardiology, 61(10_S).
Is there a standard or recommendation for how often to
change ECG electrodes?
Evidence suggests that changing EKG electrodes daily decreases the number of false alarms.
http://www.aacn.org/wd/practice/docs/practicealerts/alarm-management-practice-alert.pdf
Should nurses be allowed to adjust default alarm settings?
Are there guidelines available?
Default settings are programmed into the monitors by clinical / biomedical engineers.
Settings should be revised to eliminate duplicate alarms and so that alarms are clinically
significant and actionable- nurses should be educated to prospectively individualize alarm
parameters so that alarms are meaningful & actionable (Graham & Cvach, 2010)
Graham, K.C. & Cvach, M. (2010). Monitor alarm fatigue: Standardizing use of physiological
monitors and decreasing nuisance alarms. American Journal of Critical Care, 19(1), 28-34.
FAQs on Alarm Management
June, 2014
Advancing Safety in Medical Technology. (2011). A siren call to action: Priority issues from the
Medical Device Alarm Summit. Retrieved from
http://www.aami.org/htsi/alarms/pdfs/2011_Alarms_Summit_publication.pdf
Gross, B., Dahl, D., & Nieson, L. (2011). Physiologic monitoring alarm load on
medical/surgical floors of a community hospital. Biomedical Instrumentation & Technology,
45(1), 29-36. doi:http://dx.doi.org/10.2345/0899-8205-45.s1.29
Sendelbach,S. & Funk, M.(2013). Alarm fatigue: A patient safety concern. AACN
Advanced Critical Care, 24(4), 378-388.
Are educational resources/competencies available for staff
regarding clinical alarm management?
Which interventions will result in the greatest alarm
reduction?
Welch, J. (2011). An evidence-based approach to reduce nuisance alarms and alarm fatigue.
Biomedical Instrumentation & Technology, 45(1), 46-52. doi:http://dx.doi.org/10.2345/08998205-45.s1.46
Link to Staff Education/Competency and/or section on NACNS Alarm Safety Crosswalk
EBP utilization for telemetry monitoring. An analysis of 1095 adult patients with cardiac
telemetry on medical surgical and progressive units (non-ICU), at 4 teaching hospitals. More
than 30% of all telemetry days did not meet accepted indications for monitoring.
Benjamin, E.M., Klugman, R.A., Luckmann, R., Fairchild, D.G., & Abookire, S.A. (2013). Impact
of cardiac telemetry monitoring on patient safety and cost. American Journal of Managed
Care, 19(6), 225-232.
Drew, B. J., Califf, R. M., Funk, M., Kaufman, E. S., Krucoff, M. W., Laks, M. M., & Van Hare, G.
F. (2004). Practice Standards for Electrocardiographic Monitoring in Hospital Settings An
American Heart Association Scientific Statement From the Councils on Cardiovascular
Nursing, Clinical Cardiology, and Cardiovascular Disease in the Young: Endorsed by the
International Society of Computerized Electrocardiology and the American Association of
Critical-Care Nurses. Circulation, 110(17), 2721-2746.
http://circ.ahajournals.org/content/110/17/2721.full.pdf+html
Defaults / Parameters
How can I ensure/demonstrate appropriate staff decision
making regarding alarm parameters?
One strategy is to use case studies. Select cases for patients that are most often seen in your
practice area and create key questions. For example, for heart failure patients, how many
PVCs would the provider treat? If the patient’s normal pulse ox is 85%, what would be an
appropriate setting? 82%? 80%? Ask providers what do they want to be notified about – ask
FAQs on Alarm Management
Are there established default settings for physiologic
monitoring? Are they evidence-based? Are they variable
based on the level of acuity?
How can I sort out multi-parameter monitors and eliminate or
reduce duplicate alarms?
How do I determine the current default settings?
Fatigue
How can I measure alarm fatigue?
June, 2014
if that is how the parameters can be set.
Link to Best Practices section on NACNS Alarm Safety Crosswalk
There is no evidence that recommends particular default settings. There is evidence that will
guide you to how changes in defaults can decrease the number of alarms. Defaults are a
starting point, if specific default values are not appropriate for individual patients,
customization is essential.
Korneiwicz, D.M., Clark, T., & David, Y. (2008). A national online survey on the effectiveness
of clinical alarms. American Journal of Critical Care, 17(1), 37-41.
Each brand of monitor is set up differently. Consult with the clinical liaison from your
monitoring company, ask very specific questions. If an alarm assessment has not been
completed, that may be helpful. Evaluate the need for each parameter to be on as a default,
i.e., do all patients need continuous respiratory rate monitoring?
Some organizations have the same defaults for all monitors; others have specific defaults
for specific units. One strategy to decide on defaults is to analyze data for particular
values (eg, HR, RR, BP) over a period of time (possibly a week) and use that information to
decide what values specific defaults should be.
Link to Defaults section on NACNS Alarm Safety Crosswalk
Healthcare Technology Foundation Clinical Alarms Survey
http://www.thehtf.org/clinical.asp
Korneiwicz, D.M., Clark, T., & David, Y. (2008). A national online survey on the
effectiveness of clinical alarms. American Journal of Critical Care, 17(1), 37-41.
Data
What types of reports are available from my equipment? How
can I partner with the equipment vendors?
How can I obtain data from my monitor system?
Technology
Each vendor has different reports available. It is important to organize the information you
need and meet with the vendor and the clinical / biomedical engineers. Be specific about the
data you need, the frequency you need the report and a plan for dissemination (e.g.,
monthly or weekly reports).
Collaborate with clinical / biomedical engineers and the monitor vendor. Establish concrete
data points that are available from the monitor, work to set up ongoing reports, supplied by
either clinical / biomedical engineers or the monitor vendor. Be very clear about the data
request: what data; from which units; how often. Establish a plan for data analysis and
dissemination.
FAQs on Alarm Management
How can I test clinical alarms for audibility?
What is the best process for monitoring telemetry? How
many patients should a monitor tech be in charge of? What is
best process for notifying nurse of an alarm? When should an
alarm be escalated?
Miscellaneous
Does the hospital receive additional reimbursement for a
patient on telemetry?
How do I obtain information (or who do I contact) regarding
serious safety event data?
Who are the key stakeholders? Who should I include on my
multidisciplinary team to address clinical alarms?
Should I try to address all clinical alarms, or just cardiac
monitoring? What about specialized alarms, like fetal
monitoring?
June, 2014
Descriptive analysis of noise levels in John Hopkins Hospital; particular at night.
Busch-Vishniac, I. J., West, J. E., Barnhill, C., Hunter, T., Orellana, D., & Chivukula, R. (2005).
Noise levels in Johns Hopkins hospital. The Journal of the Acoustical Society of America,
118(6), 3629-3645.
There are no outcome data to support one type of telemetry model (eg, local telemetry
techs, “war room” model of telemetry techs, nurse accountability without tele techs). There
is no evidence to specify how many monitors one technician can observe. If a tele tech needs
to notify a nurse, the best strategy is through direct communication via an individual phone
or communication device. Whenever there is an intermediary, there is a risk for delayed or
dropped communication.
An alarm should be escalated when the risk of the alarm going unanswered could possibly
result in patient harm.
Most hospitals are paid based on negotiated contracts. On admission, the hospital is
reimbursed per DRG by most payers, including Medicare. Rarely, commercial contracts may
pay more for patients on telemetry, but it would need to be on a pre-negotiated contract.
Data on serious safety events is aggregated by different people in different organizations.
Some examples of resources for the data include risk management; the office of patient
safety; and the office of regulatory compliance.
Link to the AACN and AAMI websites on NACNS Alarm Safety Crosswalk
This is an organizational decision. The NPSG requires that you identify alarms that could
result in harm if not attended to in a timely way, the focus of the work needs to prioritize
those alarms.