Time to Battle Alarm Fatigue

Better Monitoring and Management

Laura A. Stokowski, RN, MS

Disclosures

February 20, 2014

In This Article

Alarm Management Solutions

Maria Cvach explains that today's monitors work on the principle of threshold science, and each alarm (heart rate, oxygen saturation, blood pressure) has a separate threshold. When the threshold is reached, the alarm goes off. Therefore, the number of alarms could be reduced either by changing the threshold (lowering or raising it) or building in a delay, and both of these strategies have been applied with some success (separately or combined) in different patient care areas. Here are some examples:

In an adult step-down unit, SpO2 alarms dropped by 63% by reducing the standard low SpO2 alarm limit threshold from 90% to 88%.[14]

In an intensive care unit, introducing a 19-second delay removed 67% of the alarms that occurred in the course of patient care.[15]

Combining a threshold reduction from 90% to 88% and an alarm delay of 15 seconds reduced alarms by 85%.[16]

Another way that a hospital successfully reduced its burden of alarms on one of its units was to change bradycardia, tachycardia, and heart rate limits for adults to "crisis," requiring nurses to view and act on these alarms each time they sounded, thereby eliminating self-resetting of the alarms. This reduced the weekly alarms on the pilot unit by 89% without increasing adverse events.[17]

Cvach believes that building in a delay will alleviate some of the alarm overload we are experiencing until we have better, smarter monitors. "Many alarms would be avoided if we had a delay feature that allowed us to breach the threshold for a short period of time for a change that doesn't warrant an alarm. If we could delay the alarm for a number of seconds, we could prevent the distraction to the nurse without affecting patient safety. The problem is that we haven't done any randomized controlled trials on applying delay features to physiologic monitors. We need rigorous studies to make sure that doing this doesn't affect outcomes. We need to know whether getting rid of the low-priority alarms would cause more adverse events, or would help nurses pay attention to the higher-priority alarms."

Among the alarms shut off most often are optional features, such as QT and ST-segment monitoring. Barbara Drew, RN, PhD, a professor at the University of California, San Francisco, explains why ST-segment monitoring contributes to alarm fatigue. "ST-segment monitoring is an optional feature that can be activated with current hospital monitoring equipment. However, it should not be used for patients who are unlikely to experience acute myocardial ischemia because it adds another layer of monitor alarms that contributes to alarm fatigue. A good rule of thumb for nurses to use is to activate the ST-segment monitoring feature in adults who are having troponin lab tests drawn. Troponin testing is ordered when myocardial ischemia or infarction are suspected (eg, to rule out acute coronary syndrome). These diagnoses are extremely rare in pediatric patients or adults younger than 40 years, so ST-segment monitoring alarms can generally be avoided in those populations by deactivating this feature."

A huge proportion of the nuisance alarms that occur in patient care can be prevented with some basic measures, such as proper preparation of the skin before applying the electrodes. Using good-quality electrodes and lead wires should help to minimize nuisance alarms related to equipment. In adults, this means washing with soap and water, and then rubbing the skin with a washcloth or gauze to reduce impedance and improve conductivity.[18]

In adults, electrodes should be changed daily. Evidence for this recommendation comes from a recent study conducted at Johns Hopkins Hospital, where nurses in 2 adult acute care units found that daily ECG electrode changes reduced the average number of cardiac monitor alarms by 46% per bed on both units.[19] Knowing this permits the nurse to accomplish the task during the morning bath, when time has been allotted, rather than when nuisance alarms become too frequent to be ignored and the nurse may be busy with other, more pressing tasks.

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