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

False apnea alarm in a patient breathing adequately on mechanical ventilation.

<p>The respiratory waveform (bottom tracing labelled “Resp”) has a flat line appearance. The detection of respirations from the ECG lead (impedance method) is inaccurate in this patient, displaying an erroneous respiratory rate of 4 per minute.</p

Hospital infrastructure to automatically store all physiologic monitor waveform and alarm data.

<p>Hospital infrastructure to automatically store all physiologic monitor waveform and alarm data.</p

UCSF Alarm Study Units.

<p>UCSF Alarm Study Units.</p

Comparison of Annotated Arrhythmia Alarm ICU Databases.

<p>*Annotation subset of the MIMIC II database <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0110274#pone.0110274-Aboukhalil1" target="_blank">[7]</a>. Vfib = ventricular fibrillation; Vtach = ventricular tachycardia; Brady = bradycardia; Tachy = tachycardia; VBrady = ventricular bradycardia.</p><p>Comparison of Annotated Arrhythmia Alarm ICU Databases.</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 Default Settings for Adult ICUs during the Study Period.

<p>Alarm Default Settings for Adult ICUs during the Study Period.</p

True positive ventricular tachycardia alarm using seven available ECG leads for diagnosis.

<p>Page one of the alarm annotation analysis tool shows a 10-second rhythm strip of all seven available ECG leads at the time that a ventricular tachycardia alarm was triggered. In this and subsequent Figures, ECG Leads are displayed from top to bottom in the following sequence: Lead I, II, III, V (typically V₁), aVR, aVL, aVF. As evident at the beginning of the rhythm strip, the patient has an underlying rhythm of atrial fibrillation with a rapid ventricular rate of about 140. There is an isolated ventricular premature beat (4^th beat from the end) and its QRS morphology is identical to the initial beat of the alarm event. Knowing that the event is initiated by a ventricular ectopic beat provides strong evidence that this event is a true ventricular tachycardia alarm.</p