ECG Arrhythmias and Technical Alarms during Left Ventricular Assist Device (LVAD) Therapy and its Potential Impact on Alarm Fatigue

AbstractBackground: During alarm fatigue, true alarms can go unnoticed placing patients at risk for untoward outcomes. Patients with a left ventricular assist device (LVAD) may create challenges during electrocardiographic (ECG) monitoring due to technical alarms (i.e., artifact, ECG leads off), noise and vibrations associated with LVADs, and being able to tolerate some arrythmias. Clinical Nurse Specialists play a central role in and developing evidenced based strategies to improve alarm safety with the ultimate goal of improving patient outcomes. Purpose/Aim: In this case series, we analyze three patients being treated with an LVAD device in the cardiac intensive care unit (ICU) and determine: 1) the number and type of audible arrhythmia alarms; 2) the number of true versus false arrhythmias; 3) the number, type and duration of technical alarms; and 4) report alarm burden. Methods: Secondary analysis using data from the University of California, San Francisco (UCSF) Alarm Study. Results: There were a total of 547 arrhythmia alarms and 98% were false. There were 25,232 technical alarms. Of 514 total hours of ECG monitoring, technical alarms occurred for 65.9 (13%) hours. Alarm burden of 50.15 alarms per monitored hour in the ICU. Conclusion: Audible arrhythmia alarms are common in LVAD patients, and the vast majority are false. Importantly, none of the arrhythmia alarms led to an untoward event (i.e., code blue or death). Technical alarms are also very common and occur for hours during routine ECG monitoring. Continuous ECG monitoring creates unique challenges in LVAD patients. Future studies are needed to explore strategies, both clinical and algorithm bases, to improve the accuracy of arrhythmia detection and minimize technical alarms in LVAD patients

False alarm reduction in critical care

High false alarm rates in the ICU decrease quality of care by slowing staff response times while increasing patient delirium through noise pollution. The 2015 PhysioNet/Computing in Cardiology Challenge provides a set of 1250 multi-parameter ICU data segments associated with critical arrhythmia alarms, and challenges the general research community to address the issue of false alarm suppression using all available signals. Each data segment was 5 minutes long (for real time analysis), ending at the time of the alarm. For retrospective analysis, we provided a further 30 seconds of data after the alarm was triggered. A total of 750 data segments were made available for training and 500 were held back for testing. Each alarm was reviewed by expert annotators, at least two of whom agreed that the alarm was either true or false. Challenge participants were invited to submit a complete, working algorithm to distinguish true from false alarms, and received a score based on their program's performance on the hidden test set. This score was based on the percentage of alarms correct, but with a penalty that weights the suppression of true alarms five times more heavily than acceptance of false alarms. We provided three example entries based on well-known, open source signal processing algorithms, to serve as a basis for comparison and as a starting point for participants to develop their own code. A total of 38 teams submitted a total of 215 entries in this year's Challenge. This editorial reviews the background issues for this challenge, the design of the challenge itself, the key achievements, and the follow-up research generated as a result of the Challenge, published in the concurrent special issue of Physiological Measurement. Additionally we make some recommendations for future changes in the field of patient monitoring as a result of the Challenge.National Institutes of Health (U.S.) (Grant R01-GM104987)National Institute of General Medical Sciences (U.S.) (Grant U01-EB-008577)National Institutes of Health (U.S.) (Grant R01-EB-001659

MS

thesisThe purpose of this study was to determine how often a false electrocardiogram (ECG) alarm occurred in an intensive care unit (ICU) or coronary care unit (CCU). Nine patients were monitored for 12-1/2 hours. The false alarms that occurred were documented and the cause was noted. Five patients were male with a mean age of 64 years, and four were female with a mean age of 57. Two patients were studied in the Respiratory (RICU), two in the Thoracic (TICU), and five in the CCU. The investigator studied whether a monitor could be developed that would be able to decrease the false alarm frequency by using a multiple ECG signal system, or a multiple physiologic signal system with the addition of an arterial pressure waveform. Fourteen false alarms occurred during the monitoring period with one true alarm. The frequency of false alarms was 4.2 in the RICU, 12.6 in the TICU, and 10.5 in the CCU; showing a much higher rate of false alarms per patient in the RICU. The frequency of false alarms could have been reduced by 60% with the addition of a multiple ECG signal system. Use of a multiple physiologic signal system however, would eliminate all of the false alarms and, therefore, would be a better system. No monitor that utilizes such a system has been developed, but it would be a great benefit to reduce the stress and noise level in the ICU/CCU

Multimodal Signal Processing for Diagnosis of Cardiorespiratory Disorders

This thesis addresses the use of multimodal signal processing to develop algorithms for the automated processing of two cardiorespiratory disorders. The aim of the first application of this thesis was to reduce false alarm rate in an intensive care unit. The goal was to detect five critical arrhythmias using processing of multimodal signals including photoplethysmography, arterial blood pressure, Lead II and augmented right arm electrocardiogram (ECG). A hierarchical approach was used to process the signals as well as a custom signal processing technique for each arrhythmia type. Sleep disorders are a prevalent health issue, currently costly and inconvenient to diagnose, as they normally require an overnight hospital stay by the patient. In the second application of this project, we designed automated signal processing algorithms for the diagnosis of sleep apnoea with a main focus on the ECG signal processing. We estimated the ECG-derived respiratory (EDR) signal using different methods: QRS-complex area, principal component analysis (PCA) and kernel PCA. We proposed two algorithms (segmented PCA and approximated PCA) for EDR estimation to enable applying the PCA method to overnight recordings and rectify the computational issues and memory requirement. We compared the EDR information against the chest respiratory effort signals. The performance was evaluated using three automated machine learning algorithms of linear discriminant analysis (LDA), extreme learning machine (ELM) and support vector machine (SVM) on two databases: the MIT PhysioNet database and the St. Vincent’s database. The results showed that the QRS area method for EDR estimation combined with the LDA classifier was the highest performing method and the EDR signals contain respiratory information useful for discriminating sleep apnoea. As a final step, heart rate variability (HRV) and cardiopulmonary coupling (CPC) features were extracted and combined with the EDR features and temporal optimisation techniques were applied. The cross-validation results of the minute-by-minute apnoea classification achieved an accuracy of 89%, a sensitivity of 90%, a specificity of 88%, and an AUC of 0.95 which is comparable to the best results reported in the literature

Patient Monitoring Systems

book chapterBiomedical Informatic

Analysis of Patient Alarms in Adult Intensive Care Units

...Our study aims were pretty straight-forward. We concentrated quite a bit on arrhythmia alarms, which is a little different than the parameter alarms we\u27ve been talking about so far today. We decided we were going to assess the alarm prevalence of patient\u27s physiological monitor alarms. We\u27ll identify the alarm burden, analyze a select high priority number of arrhythmia alarms and determine patient characteristics that may be associated with the frequent alarms

Single-modal and Multi-modal False Arrhythmia Alarm Reduction using Attention-based Convolutional and Recurrent Neural Networks

This study proposes a deep learning model that effectively suppresses the false alarms in the intensive care units (ICUs) without ignoring the true alarms using single- and multimodal biosignals. Most of the current work in the literature are either rule-based methods, requiring prior knowledge of arrhythmia analysis to build rules, or classical machine learning approaches, depending on hand-engineered features. In this work, we apply convolutional neural networks to automatically extract time-invariant features, an attention mechanism to put more emphasis on the important regions of the input segmented signal(s) that are more likely to contribute to an alarm, and long short-term memory units to capture the temporal information presented in the signal segments. We trained our method efficiently using a two-step training algorithm (i.e., pre-training and fine-tuning the proposed network) on the dataset provided by the PhysioNet computing in cardiology challenge 2015. The evaluation results demonstrate that the proposed method obtains better results compared to other existing algorithms for the false alarm reduction task in ICUs. The proposed method achieves a sensitivity of 93.88% and a specificity of 92.05% for the alarm classification, considering three different signals. In addition, our experiments for 5 separate alarm types leads significant results, where we just consider a single-lead ECG (e.g., a sensitivity of 90.71%, a specificity of 88.30%, an AUC of 89.51 for alarm type of Ventricular Tachycardia arrhythmia

False arrhythmia alarm suppression using ECG, ABP, and photoplethysmogram

Thesis (M. Eng.)--Massachusetts Institute of Technology, Dept. of Electrical Engineering and Computer Science, 2009.This electronic version was submitted by the student author. The certified thesis is available in the Institute Archives and Special Collections.Cataloged from student-submitted PDF version of thesis.Includes bibliographical references (p. 91-93).A signal quality assessment scheme for the photoplethysmogram waveform recorded by a pulse oximeter has been created. The signal quality algorithm uses statistical methods on time-series and spectral analysis to locate high-frequency segments of the photoplethysmogram waveform. A photoplethysmogram pulse onset detector has been implemented for heart rate estimation. Application of the signal quality metric and photoplethysmogram pulse onset detector are demonstrated in an algorithm which suppresses false electrocardiogram critical arrhythmia alarms issued by bedside monitors in hospital intensive care units.by Anagha Vishwas Deshmane.M.Eng