Effect of Nursing Interventions on Physiologic Monitor Alarm Rates

Introduction: Physiologic monitors play a vital role in saving patients' lives but expose clinicians to an overwhelming number of alarms, many of which are false. Objective: Our study aims were; a) to determine whether the mean hourly oxygen saturation (SpO2) low-limit alarm rates could be reduced by modifying the default alarm setting and b) to determine whether there would be a reduction in mean hourly technical and critical arrhythmia alarm rates and the mean percentage of false-positive critical arrhythmia alarms following daily skin preparation and the application of high-quality ECG electrodes. Methods: We conducted a prospective randomized clinical trial in two neuroscience intensive care units, collecting data during two assessment periods. Each patient's alarm rate was calculated as the number of unique alarms divided by monitoring time. Critical arrhythmia alarms were determined (true vs. false positive) using a protocol. Means and standard deviations of the hourly alarm rates and the mean percentage of false-positive critical arrhythmia alarms were determined during both assessments. A negative binomial regression was performed to test the main effect of unit, the main effect of assessment, and the unit by assessment interaction. Results: The combined use of a lower SpO2 low-limit threshold and increased alarm delay resulted in a significant unit-by-assessment interaction (p <. 001). During Assessment 2, the experimental unit had a lower mean hourly SpO2 alarm rate while in the control unit, the rate increased. No significant unit-by-assessment interactions were observed for the mean hourly technical alarm rates; during Assessment 2, both units experienced an increase in ECG lead fail alarm rates and although both units had a reduction in mean hourly artifact alarms, it was insignificant. Similarly, no significant unit-by-assessment interaction in the mean hourly critical arrhythmia alarm rate was observed; no reduction in critical arrhythmia alarm rates was found in the experimental unit. Likewise, the intervention did not reduce the mean percentage of false-positive critical arrhythmia alarms. Conclusion: A lower SpO2 alarm limit and increased alarm delay safely reduces non-actionable alarms. However, our novel electrode regimen does not reduce critical arrhythmia and technical alarm rates or false-positive arrhythmia alarms

Patient Characteristics Associated with False Arrhythmia Alarms in Intensive Care [Abstract 19717]

Introduction: A high rate of false arrhythmia alarms leads to clinical alarm fatigue, i.e. desensitization and inappropriate silencing of alarms

Insights into the problem of alarm fatigue with physiologic monitor devices: a comprehensive observational study of consecutive intensive care unit patients.

PurposePhysiologic monitors are plagued with alarms that create a cacophony of sounds and visual alerts causing "alarm fatigue" which creates an unsafe patient environment because a life-threatening event may be missed in this milieu of sensory overload. Using a state-of-the-art technology acquisition infrastructure, all monitor data including 7 ECG leads, all pressure, SpO(2), and respiration waveforms as well as user settings and alarms were stored on 461 adults treated in intensive care units. Using a well-defined alarm annotation protocol, nurse scientists with 95% inter-rater reliability annotated 12,671 arrhythmia alarms.ResultsA total of 2,558,760 unique alarms occurred in the 31-day study period: arrhythmia, 1,154,201; parameter, 612,927; technical, 791,632. There were 381,560 audible alarms for an audible alarm burden of 187/bed/day. 88.8% of the 12,671 annotated arrhythmia alarms were false positives. Conditions causing excessive alarms included inappropriate alarm settings, persistent atrial fibrillation, and non-actionable events such as PVC's and brief spikes in ST segments. Low amplitude QRS complexes in some, but not all available ECG leads caused undercounting and false arrhythmia alarms. Wide QRS complexes due to bundle branch block or ventricular pacemaker rhythm caused false alarms. 93% of the 168 true ventricular tachycardia alarms were not sustained long enough to warrant treatment.DiscussionThe excessive number of physiologic monitor alarms is a complex interplay of inappropriate user settings, patient conditions, and algorithm deficiencies. Device solutions should focus on use of all available ECG leads to identify non-artifact leads and leads with adequate QRS amplitude. Devices should provide prompts to aide in more appropriate tailoring of alarm settings to individual patients. Atrial fibrillation alarms should be limited to new onset and termination of the arrhythmia and delays for ST-segment and other parameter alarms should be configurable. Because computer devices are more reliable than humans, an opportunity exists to improve physiologic monitoring and reduce alarm fatigue

La Correspondencia de España : diario universal de noticias: Año XXII Número 4852 - 1871 marzo 11

PURPOSE: Physiologic monitors are plagued with alarms that create a cacophony of sounds and visual alerts causing "alarm fatigue" which creates an unsafe patient environment because a life-threatening event may be missed in this milieu of sensory overload. Using a state-of-the-art technology acquisition infrastructure, all monitor data including 7 ECG leads, all pressure, SpO(2), and respiration waveforms as well as user settings and alarms were stored on 461 adults treated in intensive care units. Using a well-defined alarm annotation protocol, nurse scientists with 95% inter-rater reliability annotated 12,671 arrhythmia alarms. RESULTS: A total of 2,558,760 unique alarms occurred in the 31-day study period: arrhythmia, 1,154,201; parameter, 612,927; technical, 791,632. There were 381,560 audible alarms for an audible alarm burden of 187/bed/day. 88.8% of the 12,671 annotated arrhythmia alarms were false positives. Conditions causing excessive alarms included inappropriate alarm settings, persistent atrial fibrillation, and non-actionable events such as PVC's and brief spikes in ST segments. Low amplitude QRS complexes in some, but not all available ECG leads caused undercounting and false arrhythmia alarms. Wide QRS complexes due to bundle branch block or ventricular pacemaker rhythm caused false alarms. 93% of the 168 true ventricular tachycardia alarms were not sustained long enough to warrant treatment. DISCUSSION: The excessive number of physiologic monitor alarms is a complex interplay of inappropriate user settings, patient conditions, and algorithm deficiencies. Device solutions should focus on use of all available ECG leads to identify non-artifact leads and leads with adequate QRS amplitude. Devices should provide prompts to aide in more appropriate tailoring of alarm settings to individual patients. Atrial fibrillation alarms should be limited to new onset and termination of the arrhythmia and delays for ST-segment and other parameter alarms should be configurable. Because computer devices are more reliable than humans, an opportunity exists to improve physiologic monitoring and reduce alarm fatigue

Physiologic monitor device in Intensive Care Unit.

<p>Bedside patient monitor (GE Healthcare, Milwaukee, WI) displays multiple physiologic waveforms and vital sign measurements. The nurse pictured here gave written informed consent to publish this photograph supplied by the San Francisco Chronicle newspaper (with permission) for their story on alarm fatigue at: <a href="http://www.sfgate.com/health/article/Hospitals-look-to-reduce-danger-of-alarm-fatigue-4918018.php" target="_blank">http://www.sfgate.com/health/article/Hospitals-look-to-reduce-danger-of-alarm-fatigue-4918018.php</a>.</p

ST-Segment Alarm Durations in a 16-Bed Cardiac ICU.

<p>ST-Segment Alarm Durations in a 16-Bed Cardiac ICU.</p

Low amplitude QRS in a patient with an excessive number of alarms.

<p>Standard “diagnostic” 12-lead ECG recorded from the patient who contributed nearly half of the 12,671 arrhythmia alarms for annotation. The ECG shows left bundle branch block with low amplitude QRS complexes in the limb leads but not in the V leads. Since one of the available leads acquired with the physiologic patient monitoring device is a V lead, the arrhythmia algorithm could have avoided the excessive number of false alarms had all available leads been used for QRS detection.</p

Frequency of all unique alarms (N = 2,558,760) over a 31-day period.

<p>Frequency of all unique alarms (N = 2,558,760) over a 31-day period.</p

Alarm Annotation Protocol.

<p>Alarm Annotation Protocol.</p

False accelerated ventricular rhythm alarm in a patient with ventricular pacing.

<p>Patient with atrial fibrillation and intermittent ventricular pacing does not have PaceMode activated. As a result, a period of ventricular pacing goes undetected by the algorithm (no pacemaker spikes are “painted” in) and a false alarm is generated of accelerated ventricular rhythm. The investigators determined this to be intermittent pacing (rather than accelerated ventricular rhythm) because the rate matched the pacemaker heart rate setting. Moreover, the QRS morphology across all 7 leads matched the QRS morphology of corresponding leads on a hospital-acquired standard “diagnostic” 12-lead ECG during a known period of pacing.</p