Presentation Title
Sub Information
Strategies
for
Managing
Alarm
Fatigue
Presentation Title
An Evidence-Based Approach for Understanding and Managing Alarm Fatigue
Sub Information
in the Acute and Critical Care Environment
May 2013
Copyright © 2013 American Association of Critical-Care Nurses
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Learning Outcomes
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Describe the causes and impact of alarm fatigue.
Outline the causes of nuisance and false-positive alarms.
Explain the impact of alarm fatigue on patient safety.
Summarize the impact of false-positive and nuisance alarms on
patient safety.
 Examine the evidence-based implementation strategies for
improving
patient safety.
Sub
Information
 List nurse-led strategies for individualizing patients’ alarm
parameters.
Presentation Title
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The Extent of the Problem
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Unintended Consequences—Patient Death
Since 2005, more than 216 patient deaths have been directly
attributed to alarm fatigue.
2007
 77-year old was admitted to a telemetry unit.
 Alarms for “low battery” went unanswered.
 Patient had cardiac arrest and died.
January 2010
 89-year-old patient was in the ICU.
 Bedside alarm was turned off.
 Alarmed sounded at the central nurses’ station.
 Nurses on duty said they did not hear the alarm or see the digital
display.
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Unintended Consequences—Patient
Death (cont’d)
August 2010
 60-year-old man was admitted to the ICU after a tree fell on him,
resulting in facial trauma and head injury.
 He was agitated and received lorazepam 5 mg IV push. The order
was for “small doses up to 5 mg.”
 An hour later, tachycardia and low oxygen saturation (SpO2) alarms
went unanswered for an hour.
 Respiratory arrest was called. Patient was resuscitated and placed
on a ventilator.
 CT scan showed an anoxic injury of the brain.
 Family withdrew the patient from life support after several days.
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Defining the Problem
Alarm Fatigue
 Occurs when staff members are exposed to an excessive
number of alarms.
 Staff become desensitized to alarms.
 Results in sensory overload:
— Staff frustration
— Delayed alarm response
— Missed alarms
— Patient safety events
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Contributing Factors
Nuisance Alarms
 May interfere with patient care.
 Are perceived as annoying.
 Are not the result of adverse patient conditions.
 Distract from other tasks or focus.
False Alarms
 Are detected by a medical device.
 Indicate the need for a response.
 Are triggered without a true patient event.
 Are usually the result of:
http://en.ecgpedia.org/wiki/Main_Page
— Parameters not set to actionable levels
— Too tight thresholds
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The Reality
Technology
 Natural part of the environment
Physiologic monitoring
 Standards of care and practice
Devices
 Only as reliable as the clinicians who use them
Alarms
 Inherent in the clinical environment
 Intended to alert clinicians to deviations from a predetermined
“normal” status
 Compromise patient safety if ignored
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Staff Perceptions
 Alarms are a necessary evil.
 May not view alarm fatigue as a problem or real threat to
patient safety.
 Alarms may be used as a stop-gap measure for a lack of
monitoring.
 Use of alarms is a possible means to eliminate and/or replace
staff or clinicians with technology.
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Rethinking What We Do
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Rethinking What We Do
Alarm fatigue is a complex issue:
 Unique set of circumstances and vulnerabilities
— Hospital and organizational culture
— Nuisances specific to patient unit
 Many variations of common problems
— Apathy for “leads off” and “low battery” alarms
— Communication breakdowns
— Competing priorities
 Alarm data are difficult to obtain
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Rethinking What We Do (cont’d)
2011 ECRI Institute Report
 Staff overloaded with alarms will
improperly modify alarm setting.
 Alarm settings should be modified
only after careful consideration of
each patient’s condition.
https://www.ecri.org/Documents/Alarm-Management-Safety-Review.pdf
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Proactive Response
The best way to prevent alarm fatigue is through proactive alarm
management.
 Inquire whether you have the ability and authority to adjust
alarms of physiologic monitoring systems
 Tailor alarm parameters to the:
— Individual patient
— Specific patient population
 Evaluate whether the:
— Alarms are audible and visually displayed.
— Critical alarm sound is distinguishable over unit noises and other
alarms.
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Proactive Response (cont’d)
Decrease false-positive alarms.
 Degrade the clinician’s ability to decipher priority alarms.
 Ensure proper skin preparation technique before placing ECG
electrodes.
 Troubleshoot false alarms when they occur.
— Avoid ignoring them.
— Avoid alarm work-arounds.
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Proactive Response (cont’d)
 Do not overuse physiologic monitoring.
— Avoid keeping the patient on telemetry monitoring longer than
necessary.
— Consider the American Heart Association and American College of
Cardiology’s evidence-based Practice Standards for
Electrocardiographic Monitoring in Hospital Settings.
 Never turn off an alarm.
— Consider silencing while you troubleshoot.
— Assess the reason for the alarm.
— Intervene as appropriate.
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Managing Environmental
Alarms
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Laser Sharp Focus
Alarm Management
 Orchestration
— Culture
— Staff responsibilities
— Technology
— Policies and procedures
— Processes
 Must support:
— Prompt and efficacious alarm verification
— Notification
— Response
— Documentation
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Alarm Management Models
Alarm Prioritization
 Visual and audible distinctions of alarms are provided.
 Indicates the level of urgency of the response.
Alarm Escalation Plan
 Designates the caregiver to receive initial alarm notification.
 Identifies an additional caregiver as a backup in case no
response to the alarm occurs.
 Time intervals for escalation are
defined.
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Alarm Management Models (cont’d)
Decentralized Alarm Coverage Model
 Direct alarm notification
— From central station
— From remote displays
— From devices themselves
 Unit-based monitor watchers
— Continuous watch central station displays
— Notification directly to a patient’s nurse
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Alarm Management Models (cont’d)
Remote Centralized Monitoring Surveillance Model
 Room is separated from the care area.
 Dedicated monitor watchers are provided.
 Alarm notification is provided to the nurse via telephone or pager.
 Reduces patient and caregiver exposure to the noise and demand of
nuisance alarms.
Alarm Integration Model
 Clinical device alarms are transmitted to a central system.
 System communicates with caregiver via devices such as a pager or
telephone.
 System has potential to:
— Relay alarms only
— Attempt to filter out nuisance alarms
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Alarm Management Strategies
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Alarm Management Strategies
Must involve multidisciplinary team:
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Chief Nursing Officer
Director of Quality
Key Medical Staff
Clinical Engineering
Nurse Managers
Clinical Nurse Specialists and Educators
Frontline Nurses
Information Technology Staff
Analyze:
 Adverse events
 Near misses
 Did alarms contribute to the patient event?
Observe alarm coverage.
Survey staff regarding alarm concerns.
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Alarm Management Strategies (cont’d)
In collaboration with frontline staff, develop policies that will:
 Define specific alarm levels.
 Describe the expected response to each level.
 Identify the back-up plan, should the responsible person be unable to
respond.
— Expectations and accountability must be aligned with the principles of
a blameless culture.
— Reporting of issues is encouraged and transparent.
Develop reports that will:
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Provide a benchmark.
Provide ongoing data about predefined quality parameters.
Measure the progress.
Identify areas of focus and work to attain high levels of staff compliance.
Clinicians must immediately address alarms:
 Alarms should never be turned off.
Copyright © 2013 American Association of Critical-Care Nurses
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Alarm Management Strategies (cont’d)
Organizations should communicate to patients and visitors that prompt
responses to alarms are a top priority in keeping patients safe.
Make all alarms actionable:
 Clinicians only alerted to clinically significant alarms that require
response
 Addressed by analyzing default alarm parameters and ensuring
parameters are appropriate for the individual patient
 On-going education and validation of staff competency on
customizing alarm parameters
Copyright © 2013 American Association of Critical-Care Nurses
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Alarm Management Strategies (cont’d)
Consider a brief delay in alarm notification (5 to 10 seconds).
 Avoids alarm notification for a problem that quickly resolves.
 Important: Incorporated delay must not jeopardize quick access to
emergent care.
Implement preventive maintenance.
 Prepare the skin before applying ECG electrodes.
 Routinely replace ECG electrodes every 24 hours to prevent them
from drying out.
 Consider setting a 5- to 15-second delay for SpO2 alarms.
 Individualize SpO2 alarm threshold to the patient’s condition.
 Consider upgrading to the next-generation pulse oximetry.
 Use disposable, adhesive pulse oximetry sensors, and replace them
when no longer properly adhering to the patient’s skin.
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Alarm Management Strategies—
Ventilator Alarms
 Collaborate with Respiratory Care Practitioners.
 No standard default alarm settings exist for ventilators.
 The American Association of Respiratory Care Practitioners
published a consensus statement regarding alarms:
— Level 1: Events that are immediately threatening if left unattended for
short periods (e.g., power failure, apnea)
— Level 2: Events that are potentially life threatening if left unattended for
longer periods (e.g., circuit leak, positive-end expiratory pressure [PEEP] alarms)
— Level 3: Nonventilator events that are not likely to be life threatening but
a possible source of patient harm if not addressed.
 Consider using a 360-degree visual display screen on all high-priority
ventilator alarms. High-priority alarms are displayed in red;
medium-priority alarms are displayed in yellow.
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Core Alarm Management Strategies—
Infusion Pumps
IV Infusion Pumps
 No replacement for nursing assessment
 Proactively identify any problems that might interfere with the
prescribed infusion rate
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Core Alarm Management Strategies—
Bed Alarms
Bed-Exit Alarms
 Widely used as a fall prevention strategy
 Used only in these clinical scenarios:
— Patients with delirium and cognitive impairment
— Patients who are unable to walk without support or who
have an unsafe gait
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Return on Investment
Organizational focus likely to yield positive improvements in:
• Patient satisfaction
• Clinical outcomes
• Clinical documentation relevance
• Staff morale
• Effectiveness of the care team
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Real World Success Stories:
Examples of Successful
Alarm Management
and Patient Safety Efforts
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Johns Hopkins Hospital Experience
 Demonstrated that the number of nonactionable alarms can be
reduced:
— Thereby decreasing caregivers’ alarm burden without
compromising patient safety by making modest default parameter
changes;
— Standardizing care policies and equipment; and
— Providing reliable secondary alarm notification.
 The organization invested the time to understand the problem.
— Studied and tested various solutions
— Shared knowledge among various staff and departments
 The project was a collaborative effort, involving contributions
from nurses, physicians, clinical engineers, and IT personnel, as
well as the cooperation of the hospital’s monitor vendor.
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Massachusetts General Hospital
Experience
 The hospital approached the incident in a transparent manner and
conducted a thorough system review that led to improvements in care
delivery including:
— Holding monthly drills in the ICUs, and timing how long it takes
members of the health care team to respond to alarms
— Arranging seminars and webinars on reducing false alarms, as well as
identifying proactive ways to safeguard against alarm fatigue
— Disabling the “off” switches on 1,100 cardiac monitors
— Installing more speakers to ensure alarms are clearly heard
— Sending low-battery warnings, as well as alarms for many potential lifethreatening changes in a patient’s condition, directly to nurses’ cell
phones and pagers
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NorthShore University Health System
Experience
Four-hospital system reviewed the status of clinical alarms on medicalsurgical telemetry units.
 Multidisciplinary team consisted of staff nurses, clinical nurse
managers, clinical coordinators, physicians, risk management, nurse
educators, and biomedical engineering.
 Two different monitoring companies were in the system; one unit
from each monitoring company was chosen for pilot testing.
— First pilot unit was a 24-bed progressive care unit. After intervention,
alarms dropped from 27,000 per month to less than 12,000 (56%
reduction).
— Second pilot unit was a 40-bed unit with alarms exceeding 114,332 per
month. After intervention, alarms dropped to approximately 15,000
(87% reduction).
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Christiana Health System Experience
Developed system-wide alarm policy and protocols:
 Defined its alarm management strategy for alarmed medical
equipment, including remote continuous ECG monitors, standard
cardiac monitors, pulse oximeters, and infusion pumps
Resulted in:
 Improved patient safety and environment of care
 Shared sense of responsibility and additional support for nurses
 Improved patient throughput
Key learnings:
 An organizational approach to alarm standardization is important:
— Clinical staff work on multiple units and of various shifts
— Clinical staff must know what to expect from an alarm system
— Prevention of over-monitoring on one unit versus under-monitoring on
another
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Toolbox of Alarm Management Resources
 AACN Practice Alert (http://www.aacn.org/practicealerts)
 The Joint Commission proposal: 2014 National Patient Safety Goal on
Alarm Management
 ECRI Institute (http://www.ecri.org)
 Healthcare Technology Foundation (http://thehtf.org)
 U.S. Food and Drug Administration Medical Devices
(http://www.fda.gov/default.htm)
 Advancing Safety in Medical Technology Healthcare Technology Safety
Institute (http://www.aami.org/htsi/)
 Industry partners
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Physiologic monitoring system manufacturers
Ventilator manufacturers
Infusion pump manufacturers
Pulse oximetry device manufacturers
Bed manufacturers
Wired and wireless communication systems manufacturers
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Bibliography
ECRI Institute. Top 10 health technology hazards for 2013. Health Devices. 2012;
41(11):1-23. Available at: https://www.ecri.org/FormsPages/ECRI-Institute-2013Top-10-Hazards.aspx. Accessed December 2, 2012.
Association for the Advancement of Medical Instrumentation Foundation/Healthcare
Technology Safety Institute (AAMI Foundation/HTSI). Safety innovations: using data
to drive alarm improvement efforts. The Johns Hopkins Hospital experience.
Available at: http://www.aami.org/htsi/SI_Series/Johns_Hopkins_White_Paper.pdf.
Accessed January 9, 2013.
AAMI Foundation/HTSI). Safety innovations: recommendations for alarm signal
standardization and more innovation. The Christiana Care Health System experience.
Available at: http://www.aami.org/htsi/si_series/christiana_care_alarm_signal.pdf.
Accessed March 7, 2013.
American Association for Respiratory Care (AARC). Consensus statement on the
essentials of mechanical ventilators—1992. Respir Care 1992; 37(9):1000-1008.
Copyright © 2013 American Association of Critical-Care Nurses
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Presentation Title
Sub Information